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Diseases of the Heart 



A. L BLACKWOOD, M. D. 

PROFESSOR OF GENERAL MEDICINE AND SENIOR 
PROFESSOR OF PHYSIOLOGY IN THE HAHNEMANN 
MEDICAL COLLEGE, CHICAGO; ATTENDING 
PHYSICIAN TO THE HAHNEMANN HOS- 
PITAL, CHICAGO; MEMBER OF THE 
AMERICAN INSTITUTE OF HOM- 
EOPATHY, ILLINOIS STATE 
HOMEOPATHIC SO- 
CIETY, ETC., ETC. 



HALSEY BROS. CO. 

CHICAGO AND ST. PAUL, 

1901. 



Library of Congress 

"Two Copies Received 
FEB 25 1901 

Copyright entry 
Sja^.. 3/. '9c/ 

SECOND COPY 




COPYRIGHTED 

1901 

A. L. BLACKWOOD, M. D. 



PREFACE. 

In presenting this work to the profession the 
author does it conscious of two facts: first, that its 
contents have merit, for more than a dozen years, 
guided by the precepts laid down in it, patients both 
private and clinical have been benefited; and second, 
that there are imperfections in it; for perfection is 
a quality that few attain. 

An attempt has been made to present the differ- 
ent phases of this subject in as brief, concise and 
practical a manner as possible. Controversial topics 
have been avoided and doubtful subjects omitted. 
Much attention has been devoted to the general treat- 
ment, to make it as complete as possible, believing 
this to be the weak point in the practice of many 
physicians. In order that there may be but few 
repetitions, at different places in the book the reader 
has been referred to other articles for the indications 
for certain remedies. 

In presenting the remedies called for in a dis- 
ease but little attention has been given to their al- 
phabetical order; on the contrary, they have been 
presented in the order of their importance as ob- 
served by the writer. 

In preparing the work, the assistance has been 
derived from the standard works, current literature, 
private and clinical practice, to all of which the 
author extends thanks, as well as to the many kind 
friends who have spoken words of encouragement. 

ji Washington Street, Chicago. 

January First, Nineteen Hu?idred and One. 



CONTEXTS. 



CHAPTER I. 
The Relation of the Heart to the Chest Wall and Surrounding Organs. 

CHAPTER II. 
Clinical Examination of the Patient and Semeiology: Inspection — 
Apex Beat — Epigastric Pulsation — Palpation — Percussion — Auscul- 
tation — Cardiac Murmurs — The Arterial Pulse — Inspection and 
Palpation — Sphygmograph — Tracing — High Tensioned Pulse — 
Low Tension Pulse. Symptoms of the Digestive System— Blood 
and Glands— Respiratory System — Skin — Kidney — Reproductive 
System — Nervous System. 

CHAPTER III. 
Cardiac Pathology: Etiology — Palpation — Rheumatic Poison — Gout — 
Acute Infectious Diseases — Cloudy Swelling — Fatty Heart — Senile 
Changes — Reaction of Tissue to Irritation — Hypertrophy. 

CHAPTER TV. 

Therapeutics : General Statement — Rest — Change of Temperature — 
Diet — Stimulants — Movement of the Bowels — Anemia — Sleep — 
Mental Condition — Scarification of the Skin — Exercise — Oertel's- 
Schott's Baths — Exercise. 

CHAPTER V. 
Pericarditis: Definition — Varieties — Etiology — Pathology — Symptoms. 
Fibrinous : — Inspection — Palpation — Percussion — Auscultation. 
Serous Form: Inspection — Palpation — Percussion — Auscultation. 
Purulent — Hemorrhagic — Chronic Forms : Diagnosis — Differential 
Diagnosis — Prognosis — Treatment. 

CHAPTER VI. 
Mediastino-Pericarditis : Etiology — Pathology — Symptoms — Diagno- 
sis — Prognosis — Treatment. Adherent Pericarditis: Etiology — 
Pathology — Symptoms — Diagnosis — Prognosis — Treatment. 
Hemopericardium : Etiology — Pathology — Symptoms — Diagnosis 

— Prognosis — Treatment. Pneumopericardium : Etiology — Path- 
ology — Symptoms — Diagnosis— Prognosis— Treatment. Hydroperi- 
cardium : Etiology — Pathology — Symptoms — Diagnosis — Prognosis 

— Treatment. Pericardial Tuberculosis : Etiology — Pathology — 
Symptoms — Diagnosis — Prognosis — Treatment. Pericardial Syph- 
ilis — Neoplasms — Actinomycosis — Hydatid Cysts. 

CHAPTER VII. 
Myocarditis,. Acute : Etiology — Pathology — Symptoms — Physical Signs 
— Diagnosis — Prognosis — Treatment. Chronic : Etiology — Path- 
ology — Symptoms — Diagnosis — Prognosis — Treatment. 



CONTENTS. 



CHAPTER VIII. 

Cardiac Dilatation, Acute: Etiology — Pathology — Symptoms — Phys- 
ical Signs — Diagnosis — Prognosis — Treatment. Chronic: Etiology 
— Pathology — Symptoms — Physical Signs — Diagnosis — Differential 
Diagnosis — Prognosis — Treatment. 

CHAPTER IX. 

Cardiac Hypertrophy : Definition — Etiology — Pathology — Symptoms 
— Physical Signs — Diagnosis — Prognosis — Treatment. 

CHAPTER X. 

Fatty Heart: Definition— Fatty Accumulation with Infiltration — 
Etiology — Pathology — Symptoms — Physical Signs — Diagnosis — 
Prognosis — Treatment. Fatty Degeneration : Etiology — Pathology 
— Symptoms — Physical Signs — Diagnosis — Prognosis — Treatment. 

CHAPTER XI. 

Spontaneous Rupture of the Heart : Etiology — Pathology — Symptoms 
— Diagnosis — Prognosis — Treatment. Aneurysm of the Heart : 
Etiology — Pathology — Symptoms — Diagnosis — Prognosis — Treat- 
ment. New Formations: Tuberculosis — Cardiac Atrophy : Etiology 
— Pathology — Symptoms — Diagnosis — Prognosis — Treatment. 
Syphilis of the Heart : Etiology — Pathology — Symptoms — Diag- 
nosis — Prognosis — Treatment. Wounds of the Heart: Symptoms 
— Physical Signs — Diagnosis — Prognosis — Treatment. Amyloid 
Disease — Calcareous Degeneration. 

CHAPTER XII. 

Endocarditis : Definition — Simple Acute — Etiology — Pathology — 
Symptoms — Diagnosis — Prognosis — Treatment. 

CHAPTER XIII. 

Malignant Endocarditis : Definition— Etiology— Pathology— Symptoms 
—Typhoid Form— Septic Form— Diagnosis— Prognosis— Treatment. 

CHAPTER XIV. 

Chronic Endocarditis : Definition— Etiology— Pathology — Symptoms — 
Diagnosis — Prognosis — Treatment. 

CHAPTER XV. 

Aortic Incompetency : Definition — Etiology — Pathology — Symptoms — 
Physical Signs — Diagnosis — Differential Diagnosis — Prognosis — 
Treatment. 

CHAPTER XVI. 

Aortic Stenosis : Definition— Etiology— Pathology— Symptoms— Physi- 
cal Signs — Diagnosis — Differential Diagnosis — Prognosis — Treat- 
ment — Aortic Stenosis and Regurgitation. 



CONTENTS. 



CHAPTER XVII. 

Mitral Incompetency : Definition — Etiology — Pathology — Symptoms — 
Physical Signs — Diagnosis — Prognosis — Treatment. 

CHAPTER XVIII. 
Mitral Stenosis : Definition — Etiology — Pathology — Symptoms — Physi- 
cal Signs — Diagnosis — Prognosis — Treatment. Mitral Obstruction 
and Regurgitation : Etiology — Pathology — Symptoms — Diagnosis 
— Prognosis — Treatment. 

CHAPTER XIX. 

Pulmonary Incompetency: Definition — Etiology — Pathology — Symp- 
toms — Physical Signs — Diagnosis — Prognosis — Treatment. Pulmo- 
nary Stenosis : Definition — Etiology — Pathology — Symptoms — 
Physical Signs — Diagnosis — Prognosis — Treatment. 

CHAPTER XX. 

Tricuspid Incompetency : Definition — Etiology — Pathology — Symp- 
toms — Physical Signs — Diagnosis — Prognosis — Treatment. Tri- 
cuspid Stenosis : Definition — Etiology — Pathology — Symptoms 
— Physical Signs — Diagnosis — Prognosis — Treatment. 

CHAPTER XXI. 

Cardiac Thrombosis: Definition — Etiology — Pathology — Symptoms — 

Diagnosis — Prognosis — Treatment. Aneurysm of the Valves. 

CHAPTER XXII. 
Arrhythmia: Definition — Pulsus alternans — Pulsus bigeminus — Pul- 
sus paradoxus — Delirium cordis — Tremor cordis — Gallop Rhythm 
— Etiology — Symptoms — Diagnosis — Prognosis — Treat ment . 

CHAPTER XXIII. 

Palpitation : Definition — Etiology — Symptoms — Physical Signs — 
Diagnosis — Prognosis — Treatment. 

CHAPTER XXIV. 

Bradycardia : Definition — Etiology — Pathology — Symptoms — Diag- 
nosis — Prognosis — Treatment. 

CHAPTER XXV. 

Tachycardia : Definition — Etiology — Pathology — Symptoms — Diag- 
nosis — Prog nosis — Tre atment . 

CHAPTER XXVI. 

Angina Pectoris : Definition — Etiology — Pathology — Symptoms — 
Diagnosis — Prognosis — Treatment. 

CHAPTER XXVII. 
Nicotine Poisoning: Etiology — Symptoms — Physical Examination — 
Treatment. Weak Heart — Definition — Etiology — Pathology — 
Symptoms — Diagnosis — Treatment. 



IO CONTENTS. 



CHAPTER XXVIII. 
Congenital Heart Disease : Etiology — Pathology — Symptoms — Physical 
Signs — Diagnosis— Prognosis — Treatment. Syncope: Definition — 
Etiology — Symptoms — Diagnosis — Prognosis — Treatment. 

CHAPTER XXIX. 
Exophthalmic Goitre : Etiology — Pathology — Symptoms — Physical 
Signs — Diagnosis — Prognosis — Treatment. 

CHAPTER XXX. 

The Senile Heart: Definition — Etiology — Pathology — Symptoms — Di- 
agnosis — Treatment. Dropsy. 

CHAPTER XXXI. 
Aortitis, Acute: Definition — Etiology — Pathology — Symptoms — Phy- 
sical Signs — Diagnosis — Prognosis — Treatment. Chronic: Defini- 
tion — Etiology — Pathology — Symptoms — Physical Signs — Diag- 
nosis — Prognosis — Treatment. 

CHAPTER XXXII. 
Aneurysms of the Aorta: Definition — Etiology — Pathology — Symp- 
toms — Physical Signs — Diagnosis — Differential Diagnosis — Progno- 
sis — Treatment. Rupture of the Aorta. 

CHAPTER XXXIII. 
Acute Arteritis : Definition — Etiology — Pathology — Symptoms — Diag- 
nosis — Prognosis — Treatment. Arterio-sclerosis : Definition — 
Etiol ogy — Pathology — Diagnosis — Prognosis — Treatment . Arterial 
Degeneration, — Fatty — Hyaline. Arterial Infiltration,— Calcareous 
— Amyloid. Coronary Arteries. 



CHAPTER I. 
THE HEART, 

Its relation to the Chest Walls and Surrounding Organs. 



The heart occupies a central oblique position in 
the thoracic cavity, its base being upward, back- 
ward and to the right; while its apex is downward, 
forward and to the left. From an anterior view 
the right auricle and ventricle are all that can be 
seen, with the exception of a small portion of the 
left ventricle to the left. 

The right auricle is behind the sternum, extend- 
ing from a point one inch to the right of the right 
border of the sternum to the left border, and from 
a level with the third costal cartilage it extends 
downward to a point on a level with the seventh 
right costal cartilage. 

The right ventricle is pyramidal in shape, its 
lower boundary resting upon the central tendon of 
the diaphragm; at the apex of this pyramid is the 
pulmonary artery, at its left border is a furrow 
where it unites with the left ventricle, while on the 
right side there is a furrow where it unites with 
the right auricle. 

The left ventricle forms the left border of the 
heart as seen anteriorly, extending from the third 
left intercostal space down to the fifth intercostal 
space, where it terminates in the apex. 

The appendix of the left ventricle lies directly 
behind the third left costal cartilage, close to its 
junction with the third rib. 



1 4 THE HEART. 



The area that would be mapped out on the 
chest as indicating the position of the heart is spoken 
of as the area of deep cardiac dullness. 

The only portion of the heart not covered by 
lung tissue is a part of the right ventricle. This is 
spoken of as the area of superficial cardiac dullness: 
and is indicated by a line extending downward 
to the left of the middle of the sternum, from the 
level of the fourth costal cartilage to that of the 
sixth; its left border is indicated by a line started 
from the first point and extending along the fourth 
cartilage to its junction with the rib, and then dipping 
downward and curving outward to the apex. The 
base is indicated by a line extending from the sixth 
right costal cartilage to the apex. 

The heart is surrounded by the fibro-serous mem- 
brane, the pericardium; its base is held in position 
by the great vessels with which it is connected. 
Its posterior surface is flat, is formed by the left 
ventricle, rests upon the diaphragm, and extends 
from a level of the fifth to the eighth dorsal ver- 
tebra. 



CHAPTER II. 
CLINICAL EXAMINATION 

Of the Patient and Semeiology. 



The examination should be made systematically 
by inspection, palpation, percussion and auscultation. 
During this time the patient should occupy such a 
position that the light falls directly on the front of 
the chest, from which the clothing has been re- 
moved. It should be made when there has been 
quiet for some time, that all the organs may be 
observed in a condition as near normal as possible. 
The patient may occupy the standing, sitting or 
reclining position. 

Inspection : — In a normal condition the two sides 
of the chest are symmetrical, and any departure 
from this should be examined. A bulging of the 
precordial space or deformity about the chest wall 
might cause a displacement of the heart; or a fix- 
ation of the thorax that might result from pleural 
adhesion or fibroid disease of the lungs. Any re- 
traction of the intercostal spaces during cardiac 
systole should be noted as indicative of pericardial 
adhesions or cardiac hypertrophy with dilatation. 

Apex Beat: — In the adult this is in the fifth 
intercostal space, just within the mammillary line. It 
is most apparent in children and in those with thin 
thoracic walls, while in those with an excess of 
adipose tissue and of short thorax it may not be 
evident; in a few cases it is directly behind the 
sixth rib and as a result is hidden. The position 



1 6 CLINICAL EXAMINATION. , 

of the apex beat varies in health according to the 
position of the patient, moving to the right or left 
as the patient chooses one or the other side in re- 
pose. It also follows the movement of the dia- 
phragm in respiration. Protrusion of the thorax 
from the third to the seventh ribs and from the 
sternum to the nipple is present at times; the result 
of enlargement of the heart, which is due to hyper- 
trophy, dilatation or a distention of the pericardium 
due to an exudate. If the exudate is very large 
there will be bulging of the intercostal spaces. 

Increased force to the apex beat is noticed in 
the cardiac activity due to psychic conditions; in 
certain neurosis as Grave's disease; at the beginning 
of endocarditis; during early stages of fevers and 
hypertrophy of the heart. It is displaced to the 
outside of the mammillary line in right sided pleural 
exudate, the displacement being in proportion to the 
exudate; when marked, the apex beat may be in 
the fourth intercostal space and at the axillary line, 
This tilting of the apex beat upward is due to the 
inferior vena cava being drawn downward by the 
depression of the diaphragm. In cases of left sided 
pleural exudates and pneumo-thorax the apex is 
either hidden altogether or displaced to the right. 
In many of these cases a cardiac impulse will be 
seen to the right of the sternum from the third to 
the fifth spaces and corresponds to the base of the 
heart. A displacement of the apex beat is noticed 
to the right or left when the corresponding lung is 
retracted. Any displacement of the diaphragm up- 
ward or downward will produce a corresponding 
displacement of the heart. At times there is a com- 
plete inversion of the viscera, and in these cases the 



CLINICAL EXAMINATION. 1 7 

apex beat is found upon the right side. The car- 
diac impulse is diffused where there is retraction of 
the border of the lungs, due to superficial breathing, 
contraction of the lungs or enlarged heart. In 
cases of hypertrophy of the left ventricle, the apex 
beat may be outside of the mammillary line, and if 
the ribs and cartilage are elastic they are lifted 
with each pulsation. 

Epigastric pulsation is observed in thin indi- 
viduals as a result of the pulsations of the abdom- 
inal aorta, and is most pronounced when the heart's 
action is vigorous as in certain neurosis; when the 
stomach is distended as after a meal or when some 
new formation develops anterior to the aorta. Pul- 
sation in the hepatic veins and hypertrophy of the 
right ventricle also produces it. An aneurysm of the 
ascending aorta will produce a pulsation in the first 
and second intercostal spaces to the right of the 
sternum. While a pulsation in the first intercostal 
space on the left side, indicates an aneurysm of the 
arch of the aorta. A pleuritic effusion may partici- 
pate in the cardiac movements, and a pulsation be 
noticed as a result. A pre-systolic or systolic pulse 
may be noticed in the cervical veins, indicative of 
tricuspid incompetency. 

Palpation: — This assists and confirms inspection, 
and is best accomplished by placing the hand over 
the precordial region in such a manner that the 
tips of the fingers locate the apex beat, and the 
palm of the hand is over the heart. In this method 
-not only the apex beat, but also any friction rubs 
and thrills are at once conveyed to the hand. In 
the normal heart a slight impulse is felt which may 
be confined to the apex or extend over a larger area, 



CLINICAL EXAMINATION. 



depending upon the extent to which the lungs cover 
the apex. At times, on account of pericardial ex- 
udates or adipose tissue, the apex beat may not be 
palpable. Hypertrophy of the heart is attended 
with an increased impulse; and a degeneration, with 
a diminished impulse. The hand detects thrills 
which may be either exocardial or endocardial. If 
connected with the pericardium it will be rubbing, 
scraping and intermittent in character. While the 
endocardial thrill is continuous and purring in char- 
acter, and either pre-systolic, systolic or diastolic 
in time; exocardial thrills are irregular. 

The exocardial murmurs may not be developed 
until the ringers are pressed into the intercostal 
spaces, and are often obliterated by the patient tak- 
ing a long breath. A thrill at the apex is usually 
felt just before the first sound ( presystolic ) and in- 
dicates a mitral stenosis; a distinct systolic thrill 
felt at the second intercostal space on the right side 
of the sternum indicates stenosis of the aortic valve. 
Thrills are not common with insufficiency nor 
in disease of the valves of the right side of the 
heart. But a communication between the two sides 
of the heart often gives rise to a pronounced thrill. 
The gravity of the disease must not be judged by 
the loudness of the murmur or the clearness of the 
thrill. 

Percussion : — This is of no service apart from 
defining the size of the organ and its relation to 
surrounding structures. The area of flatness or ab- 
solute dullness of the heart corresponds to that por- 
tion of the right ventricle which is not covered by 
the lungs, and is triangular in shape; when the 
lungs are at rest its right border is at the middle 



CLINICAL EXAMINATION. 19 

of the sternum, while the left border begins at the 
upper border of the fourth costal cartilage, from 
which point it curves outward and downward, 
crossing the fourth intercostal space and the fifth 
rib until it reaches the fifth intercostal space, at 
which point it curves slightly inward until the car- 
diac dullness blends with the hepatic dullness. This 
makes an area of about two inches in the vertical 
by one and one-half inches in breadth, which varies 
slightly during inspiration and expiration. The size 
of the area of deep or relative cardiac dullness 
varies with all the changes in the size of the heart. 
In hypertrophy and dilatation the relative dullness 
is increased in certain directions; in case of the 
right side the transverse diameter is mostly increased, 
while in those of the left side, it is the vertical 
diameter that is mostly increased. The area of 
superficial dullness is increased as a result of peri- 
carditis, hypertrophy and dilatation. To find the 
upper border of absolute cardiac flatness one should 
commence at about the second costal cartilage and 
percuss downward: usually, at about the middle of 
the fourth costal, the pulmonary resonance gives 
way to cardiac dullness. To find the left border 
we begin at the mammillary line and the fourth 
rib, and percuss in parallel lines from this to the 
apex. The left border is curved. At the lower 
border the cardiac dullness is continuous with that 
of the liver. 

Absolute cardiac flatness changes with respira- 
tion, becoming smaller during inspiration and larger 
during expiration. The area of cardiac flatness is 
increased in those who have breathed superficially 
for a long time, and in cases of large accumulations 



20 CLINICAL EXAMINATION. 

of fat in the anterior mediastinum and pathological 
condition of the lungs. The area of flatness is 
diminished in deep inspiration, emphysema, collec- 
tions of fluid and gas in the plural sac, pneumo- 
thorax. 

Auscultation: — By auscultation we become famil 
iar with the normal and abnormal cardiac sounds. 
The first sound of the heart is produced by the 
closure of the auriculo-ventricular valves, the con- 
traction of the ventricle and the impulse of the 
apex of the heart against the chest wall. The por- 
tion of the first sound produced by the mitral valve 
is heard best at the apex of the heart; while that 
produced by the tricuspid valve is heard best at a 
little to the left of the lower end of the sternum. It is 
low in pitch, of long duration and booming in quality. 
It is systolic in rhythm, being synchronous with 
systole of the ventricle, the apex beat and carotid 
pulse. It is preceded by a long pause and followed 
by a shorter one, after which the second sound oc- 
curs. This is produced by the closure of the aortic 
and pulmonary valves, (semilunar) and vibration of 
the surrounding structures. 

The sound produced b}^ the aortic valve is heard 
best in the second intercostal space, to the right of 
the sternum; while that produced by the pulmonary 
is heard best in the corresponding space to the left 
of the sternum. The second sound is loudest at the 
points just mentioned and is it heard all over and 
beyond the cardiac area. The quality of the second 
sound is sharp and the pitch higher than that of 
the first sound, while its duration is shorter. The 
relation of the sounds with their intervening pauses 
have been represented as l 'lubb" — "dubb"— . The 



CLINICAL EXAMINATION. 21 

loudness of the sounds are modified by exercise, 
rest and the thickness of the chest walls. 

The sounds are strengthened by such pathologi- 
cal conditions as Basedow's disease and febrile condi- 
tions. They are weakened from enfeebled conditions 
of the heart, great loss of blood and feeble condi- 
tion of the patient. It should be remembered that 
adipose tissue or other developments might intervene 
between the heart and chest wall and muffle the 
sound. Arrhythmia is often the result of the de- 
generation of the cardiac muscle. 

When a single sound is increased, the others 
being normal or weakened, the increased sound is 
said to be accentuated. This is usually caused by 
the closure of the valves under an increased blood 
tension. Reduplication of either sound may take 
place when the valves producing the sound do not 
receive their greatest tension at the same time. 
The diastolic sound is more frequently duplicated 
than the first, or systolic. It is usually temporary 
but may be permanent and it is not peculiar to 
any particular lesion. A metallic ring to the first 
sound at the apex is usually indicative of cardiac 
hypertrophy, or increased cardiac activity in a nor- 
mal heart; with the second aortic sound it usually 
indicates atheromatous conditions of the arteries. 
Pneumo-pericardium, pneumothorax, a large cavity 
in the lung with smooth walls close to the heart 
and a gaseous distension of the stomach may give 
a metallic ring to both sounds at the apex. 

Cardiac Murmurs : — Those having origin within 
the heart are said to be endocardial, and are 
divided into organic and inorganic. The former 
are due to anatomical changes of the valves: the 



2 2 CLINICAL EXAMINATION. 

latter to changes in the cardiac muscle, anomalies 
of the blood and general diseases. The organic 
endocardial murmurs may be systolic or diastolic, 
and may be upon the right or left side of the 
heart. When systolic and upon the left side of 
the heart they are heard with the first sound. 
When heard best at the apex it indicates mitral 
regurgitation. With it there are indications of pul- 
monary, renal and hepatic congestion, and often 
edema of the feet and ankles. The left heart is 
enlarged and there is accentuation of the second 
pulmonic sound; the murmur is apt to be soft and 
blowing in quality. Its intensity does not indicate 
the severity of the lesion. Its area of greatest in- 
tensity is at the apex. It is propagated to the left 
of the apex and is often heard at the lower angle 
of the scapula; but it is not transmitted to the 
carotids, and seldom to the base of the heart. 
This is the most frequently met with of all cardiac 
murmurs. 

An aortic systolic murmur is due to obstruction 
at the aortic orifice, or a marked dilatation of the 
aorta just beyond the orifice. The pulse is small 
and wiry but regular, unless there is great cardiac 
embarrassment. A thrill is often present over the 
aortic area. Both the aortic and pulmonic second 
sounds are feeble. The murmur is harsh in quality 
with the first sound and its area of maximum in- 
tensity is in the second intercostal space to the 
right of the sternum; sometimes it is in the left; it 
is propagated to the vessels of the neck and 
towards the apex, and may be heard at the fourth 
dorsal vertebra. 

A systolic murmur on the right side of the 



CLINICAL EXAMINATION. 



heart is due either to tricuspid regurgitation or 
pulmonary obstruction. With tricuspid regurgita- 
tion there is apt to be pulmonary disease or some 
disease of the left side of the heart, and congestion 
of the brain and abdominal organs; pulsation of 
the jugular and hepatic veins are observed as a re- 
sult. The murmur is blowing in quality, replaces 
the first sound of the heart, has its area of maxi- 
mum intensity over the tricuspid area at the end 
of the sternum and has but a limited area of propa- 
gation. 

The pulmonic systolic murmur is due to ob- 
struction of the pulmonic orifice. Accompanying it 
there is evidence of venous engorgement and en- 
largement of the right heart; the pulmonic second 
sound is weak. The quality of the murmur varies, 
but is" usually harsh; it accompanies the first sound, 
its area of maximum intensity is in the second 
intercostal space to the left of the sternum. It 
may be propagated towards the left shoulder but 
not in the direction of the similar lesions at the 
aortic orifice. 

A diastolic murmur on the left side of the heart 
is due either to a mitral stenosis or an aortic re- 
gurgitation. With the mitral diastolic murmur the 
pulse is small and there is a purring presystolic 
thrill which is most distinct at the apex. There is 
pulmonary congestion, enlargement of the left 
auricle, and accentuation of the second pulmonic 
sound if the right ventricle is hypertrophied. The 
murmur is harsh and grinding in quality, long in 
duration, occurs before, and terminates with the 
first sound, and has its area of maximum intensity 
one-half an inch above the apex beat. It has a 



24 CLINICAL EXAMINATION. 

limited area of propagation, not heard to the left of 
the apex nor in the vessels of the neck. 

With the aortic diastolic murmur the pulse is 
full, strong and drops away from the finger, " Cor- 
rigan's pulse." There is a marked pulsation of the 
carotids, extending to the angle of the inferior max- 
illary and capillary pulse is often noticed. The left 
heart is hypertrophied. The murmur is soft, blowing 
and often musical in quality. In rhythm it accom- 
panies, replaces or follows the second aortic sound. 
Its area of maximum itensity is in the second inter- 
costal space to the right of the sternum; it may be 
in the second intercostal to the left of the sternum or 
at the xiphoid cartilage. Is has a wide area of 
propagation down the sternum: to the epigastrium; 
to the apex; to the carotids; radial and femoral 
arteries; and at times, down the spine. 

A diastolic murmur on the right side of the 
heart may be due to tricuspid obstruction or pul- 
monary regurgitation. With the tricuspid diastolic 
murmur there are symptoms of venous engorge- 
ment. The murmur is harsh in quality and pre- 
systolic in rythm. It is heard over the lower part 
of the sternum and is not propagated, except 
slightly toward the base. 

With the pulmonic diastolic murmur there is 
evidence of venous engorgement and pulmonary 
disease. The murmur is soft and blowing in qual- 
ity, it accompanies or replaces the second sound, 
has its area of greatest intensity in the second 
intercostal space to the left of the sternum, and 
is propagated towards the xiphoid cartilage. Func- 
tional cardiac murmurs are not constant, have no 
definite line of propagation and are always limited 



CLINICAL EXAMINATION. 25 

to the cardiac area and are not attended with en- 
largement of the heart. The anemic murmur is 
attended with symptoms of anemia, has the venous 
"hum" in the cervical veins. Pericardial friction 
sounds to and fro are superficial and are heard 
over but a limited area. Pleural friction sound 
ceases when the breath is held. 

The Pulse: — The arterial pulse is a wave of 
increased pressure passing from the center to the 
periphery of the arterial system during cardiac 
systole, and is dependent upon the amount of blood, 
the energy of the heart and the resistance of the 
blood vessels. 

Inspection : — In children the pulse is ,only visible 
in the carotids and possibly the temporal and radial 
arteries; while in the adults it may be seen at dif- 
ferent points. In arterial sclerosis, the temporal 
and some of the superficial arteries of the extrem- 
ities may be seen pursuing a tortuous course. In 
cases of aortic incompetency, the excessive pulsation 
of the carotids and superficial arteries are easily 
recognized. 

Palpation : — The arterial pulse is most satis- 
factorily papated in the radial artery, immediately 
above the wrist and between the flexor tendons and 
the prominent ridge of the radius. The patient 
should be sitting or reclining and the arm sup- 
ported at. the time. The observer should use three 
fingers in such a position that the index finger is 
nearest the heart, by this method the condition of 
the artery, the arterial tension and other points may 
be ascertained readily. When atheromatous changes 
or aneurysm are suspected, it will be necessary to 
examine both radial arteries at the same time. 



26 CLINICAL EXAMINATION. 



Sphygmograph : — This will be found of service 
in supplementing the ringer of the observer, and 
will bring into prominence and demonstrate certain 
qualities and points of the pulse not clear before, 

It should never be taken as a substitute for 
palpation, as tracings taken by different instru- 
ments, or even by the same instrument, but by dif- 
ferent operators, differ wholly in their appearance. 

In using this instrument the patient should be in 
an easy position, either reclining or sitting; the 
arm should rest easily, being supinated; the wrist 
bent backward, and the fingers partially flexed. 
The line of the radial artery should be indicated 
by a pencil. The clock work having been wound 
up it is then applied to the wrist in such a way 
that the button is over the radial artery. The 
paper having been cut to proper dimensions is then 
blackened b}^ holding it in the smoke of burning 
camphor. It is then introduced and the pressure 




Fig 2. — Typical Pulse Wave. (After Sansom.) 

adjusted to bring out the greatest amplitude of 
movement; the works are then started. To pre- 
serve the tracing it should be dipped into a satur- 
ated solution of gum dammar in equal parts of gas- 
oline and benzine. 



CLINICAL EXAMINATION. 



27 



The sphygmograph tracing of the normal pulse 
is indicated by a sudden line of ascent, which is 
followed by a more gradual line of descent, the 
latter being interrupted by two undulations. 




Fig. 3.— Normal Pulse Tracing. 

The line of ascent or percussion wave is the 
result of the entrance of the blood from the left 
ventricle into the artery, where it produces a wave 
of increased pressure. The line of descent indicates 
the gradual lessening of the arterial pressure follow- 
ing the cardiac systole. The first interruption is 
believed to be due to the current of blood passing 
along the artery. The second interruption is due 
to an outward wave of increased pressure resulting 
from a recoil of blood against the aortic cusps. 

When palpating the pulse the condition of the 
artery should be recognized. While in health it 
gives a sensation of being yielding and elastic 
under the finger, in febrile conditions it does not 
give this sensation, but is too yielding. Again it 
is hard, and rolls under the finger in advancing 
years; in arterio-sclerosis ; in chronic nephritis and 
cardiac disease. In these cases the artery is not 
only hard, but by passing the finger along the 
course of the artery it will be found to be tortuous. 
The fullness of the artery should be noticed. 

The pulse rate varies in health, being more fre- 
quent under the following conditions: in the female; 



28 CLINICAL EXAMINATION. 

in infancy; during childhood; in the upright attitude; 
in high temperature; during the latter part of the 
day; often from eating or drinking, and during 
mental or physical exertion. It is also increased 
from fevers, nervous diseases, and in almost all the 
organic heart diseases. It is slower than normal 
during the latter stages of fevers, jaundice, renal 
disease, in affections of the myocardium and 




Fig. 4— Pulse of Aortic Regurgitation. 

A high tensioned pulse should always be inves- 
tigated carefully, as it is often indicative of con- 
ditions that shorten life. It is a relative term and 
is indicated by degrees of fullness of the arteries 
between the beats. In investigating it three fingers 
should be used, and by pressure, first with the one 
nearest the heart, then the second and third, see 
how many fingers it requires to flatten the artery 
and control the wave. Being satisfied that such a 
condition exists, careful search should be made for 
the cause or causes, which is often found among 
the following: plethora, capillary contraction, resist- 
ance, old age, gout, diabetes, renal diseases, alcohol, 
sedentary habits and constipation. 

A low tensioned pulse is one where the artery 
can be easily effaced between beats and starts into 
existence by the pulse wave. The pulse may be 
large and sudden or small and easily suppressed. 



CLINICAL EXAMINATION, 



2 9 



It is found as a result of fatty degeneration of the 
heart, obesity, warmth with moisture, warm food 
and drinks, fatigue, anxiety and debility. In cases 
where atheroma and aneurysm are anticipated, the 
radial pulses should be palpated and compared 
simultaneously. In aortic stenosis the initial percus- 
sion wave is slight and gradual while the pulse 
wave is prolonged. The artery is small and full 
between the beats. In aortic incompetence the 




Fig. 5— Pulse of Aortic Stenosis. 

pulse wave is sudden and forcible, but short and 
not sustained, its cessation being abrupt, giving 
what is known as the "water hammer" or "Cor- 
rigan's pulse." The artery is large but empty 
between the beats. In mitral stenosis the pulse 
wave is long, the artery is small and full between 
beats; the tension being higher than would be 
expected. In these three the pulse is regular until 
compensation fails. In mitral regurgitation the pulse 
is usually irregular both in force and frequency. 

The dicrotic pulse is a common feature of a 
low arterial tension. Usually upon palpation of the 
radial artery but one pulsation is felt to each car- 
diac systole; but when dicrotism is present a second 
pulsation is felt immediately following the first. In 
this condition the tidal wave is absent while the 
dicrotic notch is exaggerated. When, in a sphyg- 
mographic tracing, the dicrotic notch touches the 



30 CLINICAL EXAMINATION. 

base line, it is said to be fully dicrotic; but when 
the notch sinks below the base line it is said to be 
hyperdicrotic. This condition may be produced by 
a hot bath and it is a clinical feature during the 
later stages of acute febrile diseases. 




Fig. 6— Dicrotic Pulse in Patient Convalescent from 
Typhoid Fever. 

Symptoms: — -The digestive s}*stem is frequently 
deranged as a result of circulatory disturbance. In 
venous stasis there is often nausea, vomiting and 
diarrhea, and at times hematemesis which results 
from a chronic catarrh and passive congestion. 
The patient is often troubled with meteorism, jaundice 
and hemorrhoids, on account of the interference 
with the return of blood through the hepatic veins. 

Changes are present in the blood and glands. 
Anemia may present the same blood changes as at 
any time, as regards the reduction of the hemo- 
globin; the number of red blood corpuscles; at 
times, an increase, again, a decrease of the white 
corpuscles. In cyanosis the blood is darker than 
normal, its specific gravity is increased as well as 
the amount of hemoglobin and the number of both 
red and white blood corpuscles. The reason for 
these changes are not at present clear, but the cor- 
puscles suffer a lack of proper oxygenation as a 
result of the venous stasis; their duration is increased 
on account of their function being lessened; and if 
they are produced as fast as before, it is evident 



CLINICAL EXAMINATION. 3 1 

that their number will be increased. The spleen is 
interfered with as a result of the changes in the 
portal circulation, and it is enlarged. 

The symptoms connected with the respiratory 
system, while of importance in estimating the con- 
dition of the circulatory system, are not diagnostic 
of any particular derangement of this system. 
Dyspnea or breathlessness indicates a lack of oxygen 
in the blood supplying the respirator}' center. It 
may consist of a simple breath hurry, polypnea, or 
it may be such that the patient must sit up, 
orthopnea. It may be due to a lack of oxygen or 
an excess of carbonic acid; in the former the 
dyspnea is intense, while in the latter the excess 
of carbonic acid soon brings respiration to an end. 
The dyspnea may result from an enfeebled, con- 
dition of the heart, due to myocardial and valvular 
changes, to anemia, edema of the lung, hydro- 
thorax and certain blood changes as the uremia in 
renal disease and the glycemia of diabetes. 

The respiratory rhythm may take on a periodic 
character that is known as the "Cheyne-Stokes." 
The normal respiratory rhythm is interrupted by 
periods of arrested respiration, there being an alter- 
nation in the periods of activity and repose. It 
may be observed only during sleep, or during both 
sleeping and waking hours. In watching such a 
case, it is observed that the respiratory movements 
gradually increase in extent and rapidity up to a 
certain point, and then gradually decline until a 
condition of apnea ensues, then a feeble respiration, 
and the cycle is again gone over. This is noticed 
in connection with brain, renal and cardiac diseases. 
And while noticed at times in those who are 



32 CLINICAL EXAMINATION. 

healthy, it is considered a grave symptom when 
appearing . in connection with the diseases men- 
tioned. 

Yawning and hiccough are at times annoying 
conditions that appear in connection with heart dis- 
ease. Cough is frequently the result of heart 
disease, when it may be due to bronchial catarrh; 
edema of the lungs or transudation into a pleura. 
The expectoration is more purulent if due to bron- 
chial catarrh, and of a frothy or serous character if 
due to edema of the lungs. Hemoptysis is a fre- 
quent symptom of heart disease and especially of 
the mitral valve. 

There are certain changes noticed in the skin; 
the first is the color, pallor is present as a result 
of such lesions as aortic incompetence and simple 
cardiac weakness. In aortic incompetence there is 
frequently an alternation of flushing and pallor that 
is known as the capillary pulse. Another change in 
connection with the skin is that of cyanosis which is 
seen in cases of heart failure, valvular disease and 
congenital defect of the septum. Frequently there is 
a greater degree of moisture than is natural. Swell- 
ing, due to a loss of balance between the transuda- 
tion and reabsorption of the fluid bathing the tissue, 
is a frequent symptom. This loss of balance has 
many causes, but chief among them are obstruc- 
tion to the return venous flow, and loss of aspira- 
tory power of the heart. 

The kidneys suffer as a result of the backward 
pressure, a cyanotic induration resulting. The 
amount of urine secreted is diminished, the specific 
gravity is raised, the color deepened and albumen 
is frequently present. 



CLINICAL EXAMINATION. 33 

Disturbance of the circulation interferes with 
the reproductive system. Chronic mitral lesions 
with anemia are apt to be attended with amenor- 
rhea in the female; while menorrhagia and leucor- 
rhea are common in those cardiac lesions that pro- 
duce venous stasis. 

Pain due to cardiac disease is seldom referred 
by the patient to the heart, but usually to the sur- 
face of the chest. It varies in degree from a sim- 
ple uneasiness to the angina pectoris. It is usually 
made worse by exertion, excitement and a full meal. 
The pain is more frequent on the left side than on 
the right side. This is attributed to the greater 
frequency of disease connected with the left side of 
the heart, the coronary artery and the aorta. The 
pain may be felt on the anterior or posterior por- 
tion of the chest or may extend to the shoulder 
and arm. Toxic conditions, the result of tea; 
coffee; tobacco; lithemia or glycemia, may produce 
pain. Neuritis of the cardiac nerves has been 
demonstrated in connection with disease of the 
aorta and coronary arteries. In the majority of 
cases of cardiac pain, organic lesions of some form 
are present. Where there is failure of the muscu- 
lar valves of the heart there is often a feeling as 
though the heart would stop. 



CHAPTER III. 
CARDIAC PATHOLOGY. 

The etiology of cardiac pathology divides itself 
into those cases that are inherent and those that 
are acquired. A limited experience is sufficient to 
prove to an}' one, that not only are children born 
with defective hearts, but children of parents who 
have heart disease are prone to develop similar 
lesions. Age is an important factor; acute peri- 
carditis and endocarditis are diseases of the youth, 
and are responsible for many cases of mitral dis- 
ease; while later in life appear the degenerative 
changes, as arterio-sclerosis, aneurysm, and the 
fibroid degenerative changes of the valves, espe- 
cially the aortic. 

Palpitation of the heart is frequent in early life, 
while alteration in its rhythm, due to organic dis- 
ease, appears later in life. Men suffer most from 
diseases of the aortic orifice, while women from 
those of the mitral; occupations that demand pro- 
longed physical exertion develop sclerotic changes, 
while those that are indolent develop fatty degener- 
ations. 

There is no doubt of the affinity of the rheu- 
matic poison for both the pericardium and endo- 
cardium; while gout interferes with the heart's action 
more by the degenerative changes wrought , in the 
arteries, especially the coronary, than by its direct 
action upon the heart. 

The acute infectious diseases have their effects 
upon the structure of the heart. Our knowledge of 
bacteriology has made clear how it is possible for 



CARDIAC PATHOLOGY. 35 

these effects to be brought about. Pathological 
conditions in distant organs, that interfere with the 
circulation, have most injurious effects on the heart. 

Degenerative Changes : — The heart is subject to 
various forms of degeneration. One of the most 
common is that known as cloudy swelling. The 
effects of this are noticed as a result of those acute 
infectious and local diseases that produce a profound 
impression upon the system by the toxines gener- 
ated, which modify the protoplasm; as a result, a 
swelling of the cells or fibres takes place; the lat- 
ter becoming granular and cloudy, while their 
nuclei become less distinct, and the heart as a whole 
is enlarged and presents a pale, cloudy appearance 
on section. 

Fatty heart is a term employed in speaking of 
three different conditions. In the first there is an 
extra accumulation of fat in those places where it 
is found normally. If excessive and long continued, 
it is bound to lead to functional and possibly grave, 
structural changes in the myocardium. In the 
second class, there is a deposit of fat in places 
where it does not naturally exist. It develops in 
the intermuscular septem and between the muscle 
fibres, and extends to the connective tissue under- 
lying the endocardium. In the third class, the fat 
is formed at the expense of the protoplasm of the 
cell, and replaces the muscular tissue. The change 
is brought about by changes in the blood, the 
result of certain cachexias, severe hemorrhages, 
pyrexia and toxic conditions. The tissue of the 
organ, or portion of the organ affected is paler and 
softer than normal. During certain acute diseases 
there is absorbed something that has the power of 



36 CARDIAC PATHOLOGY. 

producing coagulation: and as a result, the tissue 
breaks up into hyaline degeneration. 

While the tissue of the body generally under- 
goes a loss of bulk in advanced age, the heart 
usually goes on increasing in size; but during cer- 
tain wasting diseases and cachexias it undergoes 
atrophy, due either to a diminution in size or num- 
ber of the cell elements. In the senile changes that 
lead to fibrosis or atheroma, there is often de- 
posited the carbonate or phosphate of calcium, 
which is favored by a weakening of the circulation. 
As a result of certain cachexias, marasmus and 
senile changes, there is developed a pigmentary or 
brown atrophy. This is due to the deposit of pig- 
ments in different organs. 

The nature of the process of reaction of tissue 
to irritation, varies in degree, but not in type, 
according as it is the serous, muscular or connec- 
tive tissue that is involved. These processes may 
be exudative or proliferative, the former being 
noted during the early stages and is attended with 
leucocytes and red blood corpuscles; the latter 
occurs later and is attended with a multiplication 
of the connective tissue and endothelial cells. 
They also vary, according as the seat of the process 
is on a membrane rich in blood vessels, as the 
pericardium; or having few blood vessels, as the 
endocardium; or the myocardium where the muscu- 
lar tissue is well supplied with blood. On the 
pericardium the fluid exudate may coagulate and 
form a membrane on the surface; if an extra 
amount is thrown out on account of some bacterial 
activity, it does not coagulate but remains serous; 
while if there is greater emigration of leucocytes 



CARDIAC PATHOLOGY. 37 

with little tendency to coagulation of the serum, it 
becomes purulent. 

The endocardium covering the valves has but 
few blood vessels and as a result the process is 
greatly modified; and, while the exudation is suffi- 
cient to lead to fusion of the cusps, it is but slight 
when compared with that from the pericardium. 
The changes in the myocardium are modified by 
the tissue; the muscle cells are swollen, and lose 
their transverse striation, the nucleus is enlarged, 
the whole cell is changed in outline and is softer 
than normal. In the more chronic changes of the 
serous membrane there is thickening and contrac- 
tion of the newly formed fibrous tissue, and some- 
times, a deposit of lime salts; while in the myo- 
cardium there is hyperplasia of the connective tissue, 
which gradually leads to a disappearance of the 
muscular tissue. There is no doubt that a serous 
membrane such as the pericardium may recover 
from the effects of a pericarditis, and the endocard- 
ium may recover from an endocarditis to an extent; 
but any structural change of the myocardium is 
never recovered from. 

When the organ increases in size without any 
structural change, the process is known as hyper- 
trophy. It is recognized that in health the heart 
has a reserve strength, its task being below its 
possibilities and as a result, when an extra strain 
is brought to bear upon it, it can adapt itself to 
the emergency; first, by the reserve energy and 
then by hypertrophy which may be sufficient to 
overcome all signs of disturbance; if not, dilatation 
follows. 

Disturbances of the circulation owe their origin 



38 CARDIAC PATHOLOGY. 

to causes operating either on the heart, the blood 
vessels, or the blood itself. Those operating upon 
the heart may do so from without, as in diseases 
of the pericardium; or from within, as in diseases 
of the endocardium and also in myocardial degen- 
erations. From whatever cause the heart is weak- 
ened, both in its aspirative and expulsive action, on 
account of its reserve force it is capable of over- 
coming the resistance up to a certain point by a 
compensating hypertrophy; but hypertrophy is only 
possible when the nutrition of the heart is good. 
Of the disturbances connected with the blood 
vessels, a diminished elasticity and contractility, the 
result of advancing years, is the most important. 
Disturbances connected with the blood are varied 
in their origin and effects. In any condition that 
lowers the nutritive elements of the blood, impairs 
the heart's energy and gives rise to a loss of tone 
in the arterial walls, dilatation must result sooner 
or later. 



CHAPTER IV. 
THERAPEUTICS. 

As every organ demands a normal blood supply, 
it is evident that the treatment must include not the 
heart alone, but all organs of the body. The one 
cardinal indication for treatment is a loss of the 
equilibrium that exists in a normal state of the cir- 
culation. From the deranged hydrostatic relations 
there is an excess of blood in the veins and a de- 
ficiency in the arteries; and as a result of this ven- 
ous stasis, there is catarrh of the alimentary canal, 
the blood is imperfectly oxygenated and the kidneys 
do not eliminate the waste products. The nervous 
system suffers from the deranged functions of the 
organs, and there arises several groups of symptoms 
that constitute the basis of treatment. The heart 
has a reserve force that neutralizes all mechanical 
disturbances up to a certain point, should the ob- 
struction continue, there is a dilatation of the great 
arterial trunks, while if the stress is still continued, 
it is met by hypertrophy of the heart and later, 
dilatation takes place. 

Rest: — Of all the agencies at our disposal for 
the relief of organic heart lesions, this is one of the 
most important. It is indicated in acute pericar- 
ditis and endocarditis, in myocardial degeneration, 
both fatty and fibroid, and in all forms of myocar- 
ditis. In cases of pulmonary lesions when there is 
a break in the cardiac compensation it will be 
found of great service, also in angina pectoris, 
where there is an aneurysm of the thoracic aorta, 
and in cases of senile degeneration of the heart. 



40 THERAPEUTICS. 



Change of Temperature : — Many of these patients 
are susceptible to changes in the temperature, and 
must be protected or they will suffer from recurrent 
attacks of rheumatism. They should wear flannel 
underclothing the year round. They should not sit 
on the damp ground; should the clothing become 
damp it should be removed at once. Care should 
also be taken after perspiring that there be no chill- 
ing. These precautions should not prevent the 
patient from taking exercise and having the benefit 
of out door life. If it is possible a mild, dry, brac- 
ing, equable climate, where the patient may be in 
the open air, is to be preferred; but in the great 
majority of cases it is impossible for the patient to 
leave home, and it then becomes a question of the 
best possible home life for the case. 

When it is possible to select a residence it 
should be at a moderate elevation, there should be 
a gravelly or sandy soil, the sunshine should be 
above and the rainfall below the average; the 
water used should be soft. The house should have 
exposure to the south and be protected on the 
north and east, and should not be on an elevation 
sufficient to overtax the heart in reaching it. 

The diet should be liberal and varied, but no 
excesses should be allowed. The three meals should 
be about equal in size and at regular intervals. 
The farinaceous and vegetable articles of diet should 
be taken in due proportions, and an excess of highly 
nitrogenized foods should be avoided as they leave 
a residue that accumulates in the blood and imposes 
extra work upon the heart. 

Stimulants are needed in but few cases; when 
taken, they should be as part of a meal. 



THERAPEUTICS. 41 



It should be ascertained whether or no the move- 
ments of the bowels are sufficient at all times, as 
constipation soon leads to flatulence, palpitation and 
a higher arterial tension; due to the toxic material 
in the blood, the result of retained fecal matter. It 
is- seldom necessary to resort to cathartics, as it can 
usually be corrected by diet, exercise, massage, etc. 

Anemia is to be avoided as it always favors 
those conditions that are pernicious in the treatment 
of heart disease. The management of these cases 
resolves itself into a choice of residence, change of 
air from time to time, food, exercise, etc. 

Sleep is frequently interfered with by the cir- 
culatory disturbance and insomnia results. This 
must be avoided by the employment of such means 
as will bring rest and sleep. While these patients 
should not have their minds taxed, yet their mental 
faculties should be employed. If confined to their 
room it should have a southern exposure in order 
that plenty of light and sunshine may enter it. 
Attention should be given to the skin, lungs, kid- 
neys and bowels, that everything may be as near 
normal as possible. 

At times when the subcutaneous tissue is very 
edematous and the internal remedy is unable to re- 
move it, scarifications of the. skin about the ankles, 
allowing drainage, is often of great service, although 
attended with a degree of discomfort from soaking 
of the bed clothes; but the latter may be overcome 
by the use of needles and tubes that carry the fluid 
to a receptacle. These operations must be done 
under antiseptic precautions. 

In considering the question of exercise, the con- 
stitution, habits and strength of each case must be 



42 THERAPEUTICS. 



considered. If the patient is able to go about, the 
graduated active exercise as prescribed by Oertel 
may be adopted; if unable to go around, the re- 
sistance exercises of Schott are to be preferred. In 
the grave forms of heart disease with renal inade- 
quacy, absolute rest in bed for a few weeks, fol- 
lowed by gentle massage and cautious passive 
movements, are of service. 

The exercise recommended by Oertel consists of 
systematic graduated muscular exercise carried out 
at about two thousand feet elevation above the sea 
level. The task is walking up an incline once a 
day to a certain point, the distance, pace and eleva- 
tion being increased from day to day* With the 
exercise, the diet is carefully regulated and the 
amount of fluid taken is limited. The exercise is 
adapted to the patient, and the object it is hoped 
to attain is, to bring about a hypertrophy of the 
cardiac walls, to lessen the amount of blood by 
favoring elimination and restricting the amount of 
fluid taken. Its field of usefulness is in fatty hearts 
without degeneration or involvement of the coronary 
arteries; in cardiac dilatation and valvular diseases 
even when compensation is broken down. 

The treatment of circulatory disturbances by 
means of baths and exercise as practiced by Schott 
of Nauheim, is beneficial in certain classes of 
troubles. While there is much benefit to be de- 
rived from a residence at Nauheim, where one can 
enjoy a quiet and regulated life under the direction 
of those in charge of the baths, yet they can be 
substituted at home, and great benefit result from 
them. The baths consist of brine and effervescent 
baths. 



THERAPEUTICS. 43 



To prepare the weak brine bath with which the 
treatment should commence, one pound of sodium 
chloride and one and one half ounces of calcium 
chloride are dissolved in ten gallons of water at a 
temperature of 95 F. The duration of the first 
bath is about fifteen minutes. Each succeeding 
bath should be rendered a little stronger by the 
addition of these salts, until three pounds of sodium 
chloride and four and one half ounces of the 
calcium chloride are being used to each ten gallons 
of water. As these ingredients are being increased, 
the temperature should be gradually lowered until 
it reaches 85 ° F. and the duration of each bath 
increased until it lasts from fifteen to twenty 
minutes. 

The bath should not be taken oftener than 
every other day. Usually, in about two weeks, 
though it may require a longer period, the patient 
can tolerate the effervescent bath, which is pre- 
pared by adding to the full strength brine bath two 
ounces of sodium bicarbonate, and after mixing all 
thoroughly, three ounces of hydrochloric acid are 
added just before the bath is taken. It is best to 
have the acid in a bottle and remove the cork at 
the bottom of the bath, distributing the acid through 
the lower layers of the water. These baths are 
rendered more powerful each time, until eight 
ounces of the bicarbonate is being used and twelve 
ounces of the acid to each ten gallons of water. 

The patient should always be wrapped up and 
lie still for some time after each bath. If not used 
judiciously the baths produce restlessness aud sleep- 
lessness with loss of appetite and strength. When 
beneficial the pulse becomes slower, its volume and 



44 THERAPEUTICS. 



force being increased. If cardiac dilatation is pres- 
ent the area of cardiac dullness is diminished and 
the apex beat returns nearer its normal position. 
In order that the improvement may be permanent 
the baths and exercise to be described must be con- 
tinued for several weeks. 

This treatment will benefit cases of cardiac dila- 
tation with loss of tone, functional and neurotic 
heart disease. In mitral stenosis where compensa- 
tion is hardly broken it is often of service, but it 
should not be used in aortic disease, as attacks of 
syncope may result unless the compensation is 
broken and mitral diseases are appearing, when it 
may be beneficial. When compensation is entirely 
broken it is not as serviceable as rest in bed and 
other forms of treatment, and is contra-indicated 
in aneurysm, arterio-sclerosis and Bright's disease. 
The duration of a course of treatment is about 
four to five weeks, the effervescent bath commenc- 
ing at the end of the second week. 

The exercises which form a part of Schott's 
method of treatment are a series of simple move- 
ments of each limb made against a slight resistance 
afforded by an attendant; the object being to bring 
into action each muscle of the body. No movement 
is repeated and all are made slowly and systematic- 
ally; a short period elapsing between each move- 
ment. They are stopped if the patient experiences 
the least distress or discomfort in respiration and 
are only resumed when the patient has rested. The 
assistant stands opposite the patient and by his 
hands makes gentle resistance to the movement as 
it is performed. The patient should breath regu- 
larly and deeply. 



THERAPEUTICS. 45 



The following are the movements or exercises 
as given by the authorities at Nauheim: 

1. The arms are extended in front of the body 
at the level of the shoulder, with the palms of the 
hands touching. The two arms are then moved 
slowly outward till they are in a line with each 
other; they are then brought back to their original 
position. 

2. The arms being extended at the side of the 
body with the palms turned outwards, they are 
abducted and raised till the hands meet above the 
head; they are then brought back again in the same 
way. 

3. Each arm in turn, extended by the side of 
the body with the palms turned forward, is flexed 
at the elbow till the fingers touch the shoulder, and 
is then extended again. 

4. The arms being by the side with the palms 
of the hands turned inward they are rotated for- 
wards and upwards at the shoulder-joint till they 
are vertically extended above the head, parallel to 
each other; they are then depressed in the same 
way. 

5. The hands being clinched and turned out- 
wards and the arms extended, each forearm is flexed 
till the fingers touch the shoulder; it is then ex- 
tended. 

6. The arm is rotated at the shoulder-joint for- 
wards and upwards and then backwards and down- 
wards till a complete revolution has been performed. 

7. The arms being by the side and the palms 
turned inwards, they are moved upwards and back- 
wards as far as possible, and are then brought back 
again. 



46 THERAPEUTICS. 



8. The trunk is flexed on the hips, the knees 
being kept stiff, and is then extended again. 

9. The trunk is rotated laterally, first to the 
right and then to the left. 

10. The trunk is flexed laterally, first on one 
side and then on the other. 

it. Each leg is flexed in turn at the hip-joint, 
the knee being bent. 

12. The knee being kept straight, each leg in 
turn is raised as high as possible in front of the 
body, and then in the same way behind. 

13. Each leg in turn is then abducted as far as 
possible, the knees being kept straight. 

14. Each knee in turn is flexed, the patient 
standing on each leg alternately and supporting him- 
self with a chair. 

15. Finally, flexion and extension of the wrists 
and ankles may be practiced. 

This treatment should not be adopted on the 
mere ground that heart disease is present. When 
compensation is full no treatment is demanded, and 
better results will be obtained from this mode of 
treatment in cases of neurotic individuals with imag- 
inary heart disease, than where actual lesions are 
present. In percussing to ascertain how much the 
heart has diminished in size during the bath, allow- 
ance should be made for the deeper respirations 
taken, and as a result a greater portion of heart 
being covered by lung tissue. 



CHAPTER V. 
PERICARDITIS. 

Pericarditis is an inflammation involving the whole 
or a part of the pericardium. 

Varieties: — It may be acute or chronic; primary 
or secondary; circumscribed or diffuse; fibrinous or 
sero-fibrinous; hemorrhagic, purulent or tubercular; 
partially or totally adherent. 

Etiology: — Among the predisposing causes are: 
climatic changes, and a lowering of the resisting 
power of the body, occupations and environment 
that render the system more susceptible to noxious 
influences. While it may be found at any age, it 
is a disease of adolescence and early manhood. 
There is no such thing as idiopathic pericarditis; 
all these cases are due to infection. Injuries that 
are followed by infection are fruitful causes; of the 
more direct causes are infectious constitutional dis- 
turbances, and extension of an acute disease; as 
scarlet fever, measles, whooping-cough, small-pox, 
influenza, enteric fever, tuberculosis, syphilis and 
gonorrhea. 

In 20 per cent of the cases of rheumatism the 
pericardium is involved; the other diseases of this 
class that act as exciting causes are gout, diabetes, 
scorbutus and Bright's disease; it may result from 
extension of the inflammatory process of pleurisy, 
pleuro-pneumonia, endocarditis and myocarditis. Sep- 
tic condition, and cancerous infiltration of surround- 
ing structures have produced cases. 

Pathology: — Whether the pericarditis be local 
or general the epicardium is more affected than the 



48 PERICARDITIS. 



pericardium. When local it is most marked at the 
base of the organ around the great blood vessels. 
The membrane early becomes of a dull color, with 
ruddy tints that at times show hemorrhagic points. 
A layer of fibrin is deposited over the surface in- 
volved, which may be smooth, but more frequently 
it is roughened, due to friction. In the serous form 
the fluid may measure a gallon; and be of a yellow, 
green or grayish color. The pericarditis accom- 
panying Bright's disease has a marked tendency to 
form. adhesions, the formation of pus and the pres- 
ence of blood. Purulent pericarditis is usually the 
result of suppuration in surrounding tissue or from 
a pyemic process; the fluid is opaque, of a green- 
ish yellow color and varies in quantity. In those 
cases where decomposition of the pus has taken 
place it assumes a putrid odor and has the charac- 
teristics of putrid suppuration in other parts. The 
most favorable termination of the sero-fibrinous 
variet} 7 is a reabsorption of the exudation. There 
is usually some thickening at spots of the epicardium 
which may be so pronounced at times as to simu- 
late polypi. Usually there is more or less adhesion 
when the fluid is absorbed; the whole of the peri- 
cardial space may be obliterated. These adhesions 
may extend beyond the pericardium and involve 
the anterior chest wall, esophagus, aorta and sur- 
rounding structures. Fatty degeneration may take 
place in the new fibrous tissue and a deposit of 
organic salts, that leads to calcification, follow. 

The inflammatory process may extend to the 
mediastinum and pleura, giving rise to mediastino 
pericarditis and pleurisy. 

Symptoms: — The patient with acute pericarditis 



PERICARDITIS. 49 



chooses the recumbent posture; as the effusion be- 
comes more pronounced he then seeks the s*emi- 
recumbent position, having the shoulders raised and 
inclined to the right side; a feeling of syncope is 
noticed when the erect position is assumed. The 
face has an expression of distress and anxiety. The 
local symptoms vary with the nature of the surface 
involved. Pain is felt in the pericardial region, 
which may extend to the shoulder and left arm. 
Palpitation and dyspnea in varying degrees of 
intensity may appear. The pulse rate is increased, 
may be ioo to 130, is strong and full in the plastic 
variety, but when larger effusions have taken place 
it then becomes feeble, rapid, irregular, intermit- 
tent, dicrotic and is not in proportion to the action 
of the heart. There is usually a rise of the tem- 
perature to ioo° or 10 1 °, and it may be higher, 
while in the sub-acute, also in children, there may 
be no particular rise of temperature, no dyspnea, 
but the pulse is increased in frequency. Children 
go around all the time of the disease and complain 
but little, but before the attack there is frequently 
nervous symptoms, night terrors and restlessness. 
When vomiting appears during the course of the 
disease it is unfavorable. Difficulty in swallowing 
may appear when the esophagus is involved from 
the posterior surface of the inflamed pericardium. 
These symptoms may vary according to the clinical 
stage of the disease. 

Fibrinous Pericarditis : — At times this form 
presents no symptoms that would call attention to 
it; again they may be so marked that it is impos- 
sible to mistake them. The attack may be ushered 
in with a chill, which is followed by a fever; at 



50 PERICARDITIS. 



times the chill may not be noted, and little if any 
fever is observed. Should the pericarditis appear 
as a complication of an acute disease there is an 
increase of temperature. Dysphagia is often noted 
as well as palpitation and breathlessness. Subjective 
symptoms of uneasiness and pain about the precor- 
dia are often noted. The location of this distress 
varies, at times it is in the precordia, again it is 
the epigastric region or the left shoulder, between 
the shoulders or down the left arm, and paroxysms 
of angina pectoris is not uncommon. The action of 
the diaphragm is restricted at times, due to pain. 
Many of the symptoms of pericarditis are recog- 
nized only upon physical examination, and in those 
diseases where pericarditis often appears as a com- 
plication daily examination of the heart should be 
made to note its first appearance. 

Inspection does not reveal any change during 
the fibrinous stage apart from an increased force of 
the apex beat. 

Palpation : — Early in the history of the attack 
there is an increase in the pulse rate. After a time 
when the myocardium is involved it becomes ir- 
regular, dicrotic and of low tension. The hand 
applied over the precordia in the early stage finds 
an increased apex beat which sooner or later be- 
comes enfeebled. A friction rub is noticed which 
may be both systolic and diastolic, or only systolic. 

Percussion : — At first no enlargement of the car- 
diac area can be noted; later, a slight enlargement 
may be observed. 

Auscultation: — Shows a friction sound varying 
in intensity and quality. The murmur is increased 
by slight pressure with the stethoscope, while heavy 



PERICARDITIS. 5 1 



pressure may remove it entirely. The sound is 
heard over a limited area, its greatest intensity 
being when the patient is sitting up or leaning for- 
ward, and accompanies the cardiac movements, being 
present when the respiration is voluntarily restrained, 
eliminating pleurisy. It should be remembered that 
pericardial murmurs are occasionally heard with 
tuberculosis, cancer dryness, milk spots of the peri- 
cardium, ecchymosis of the sub-serous tissue and 
sclerosis of the coronary arteries. Fibrinous peri- 
carditis may pass away in a few hours or it may 
be followed by a serous exudate and a pericarditis 
with effusion result. 

Serous Pericarditis : — When the serous exudate 
takes place there develops some new symptoms. 
The temperature if it has been high is apt to drop. 
Nervous symptoms, as headache, lack of sleep and 
mild delirium is common. Should effusion be 
marked there is difficulty in swallowing, especially 
when the patient . is in the recumbent posture. 
Should the fever be high, the face is flushed, but 
usually the face is pale and cyanosis of the upper 
portion of the body is present; at times this may 
be general; edema is present, which may be local 
or general. The urine is scanty, of high color, and 
of a high specific gravity. Frequently the breath- 
ing is interfered with and d} T spnea is marked. If 
the effusion has appeared rapidly the respiration is 
markedly affected, if slowly there may be but little 
if any trouble. The speech may be interfered with 
in some cases, aphonia appearing as the effusion 
becomes more pronounced. The pulse is often 
irregular, of low tension, and there is distension of 
the veins of the neck. 



52 PERICARDITIS. 



Inspection shows a fullness of the precordia and 
bulging of the intercostal spaces in this region. 
The apparency of this symptom depends on the 
amount of adipose tissue present. The cardiac im- 
pulse becomes more diffused and less distinct. 

Palpation: — The cardiac impulse becomes less 
as the effusion increases until it cannot be recog- 
nized. 

Percussion: — As the effusion increases, the area 
of cardiac dullness increases aqd after an interval 
gradually disappears. The area is pear-shaped, the 
larger portion being downward. 

Auscultation: — The heart gradually becomes 
fainter and the friction murmur disappears with the 
appearance of the effusion. The complete resolution 
of the fluid usually takes place, leaving some adhe- 
sion between the epicardium and pericardium. 

Purulent Pericarditis — The symptoms of this 
variety depend upon whether it is primary, or the 
result of a secondary involvement. In some cases 
when it is a part of a general septic condition it 
may not be noticed. Again the rigor is marked, 
the temperature is high, the pulse is rapid, respira- 
tion quickened, and perspiration is profuse. 

The physical signs vary and while any and all 
symptoms may be present at times, again they are 
absent. In those cases where a serous pericarditis 
has become purulent the symptoms are pronounced. 
The rigors are followed by the characteristic tem- 
perature, pulse, respiration, with the hectic flush, 
rapid wasting and marked prostration. The pulse 
becomes irregular, dicrotic, and the area of cardiac 
dullness is increased. 



PERICARDITIS. 53 



Hemorrhagic Pericarditis : — In a great propor- 
tion of the cases blood is found in the exudate, 
especially if they accompany renal or cardiac 
disease. It is common in those cases of peri- 
carditis where cancer or tubercle is found, but in 
a less degree in the aged and alcoholics. It is 
constant in scorbutus, purpura and some of the erup- 
tive fevers. The symptoms may not be pronounced, 
but when the)' are there is a vertigo with distress 
about the chest, cold perspiration, chilliness of the 
limbs, the pulse is empty and irregular, and syncope 
is common, ending at times in death. 

Chronic Pericarditis : — This may result from an 
acute form in which resolution is not perfect, or it 
may be chronic from the beginning, in the aged, 
alcoholic, and those afflicted with kidney disease. 
When the result of an acute disease the symptoms 
are those of the stage in which the resolution 
ceased, and the chronic form began. When the 
disease is chronic from the start, pain is seldom 
complained of, but the circulation is weak, breathing 
is restricted, and there is a sensation of oppression 
about the precordia. The area of cardiac dullness 
is enlarged, the heart sounds are weakened, and 
frequently a friction murmur is detected. 

Diagnosis: — In the majority of cases it is an 
easy matter to recognize pericarditis, but when 
latent or masked it is not. The friction sound 
might be mistaken for endocardial murmurs. But 
in pericarditis it is more superficial and limited to 
the precordial region. Gentle pressure with the 
stethoscope increases the friction sound while under 
more marked pressure it is obliterated. The sound 
is more marked with the patient sitting up or lean- 



54 



PERICARDITIS. 



ing forward; while endocardial systolic sounds are 
of greater intensity while reclining. The pericardial 
friction sound rather follows the cardiac sound and 
is often to and fro. 

Pleural friction sounds will disappear if the 
breath is held. 

Tubercular pericarditis may be the result of a 
general miliary tuberculosis or of localized masses 
confined to the pericardium. 

Hydropericardium might be mistaken for peri- 
carditis but the condition of the kidneys and circu- 
lation should distinguish them. 

Differential diagnosis of pericarditis with effusion 
and dilatation of the heart: 



PERICARDITIS. 

The outline of dullness is 
pear-shaped with the enlarge- 
ment upwards. 

Usually develops rapidly. 



If an impulse is present it 
is in the third or fourth left 
intercostal space. 

Apex beat may not be dis- 
cernible, or up and outward. 

Pain over the precordia, 
and tenderness over the epi- 
gastrium often present. 

Usually attended with fever. 

Occurs during acute rheu- 
matism, Bright's disease, etc. 



DILATATION OF THE HEART. 

, The dullness is not pear- 
shaped and is largest down- 
ward. 

Usually develops slowly ; 
at times rapidly. 

When present it is lower 
than normal in the epigas- 
trium, or to the left of the 
lower part of the sternum. 

Diffused. 



These are usually absent. 



Fever is absent. 

Occurs with anemia, degen- 
eration of the myocardium, 
and chronic valvular diseases. 



PERICARDITIS. 55 



PERICARDITIS. CARDIAC HYPERTROPHY. 

Develops rapidly. Develops slowly. 

The pulse is weak, quick The pulse depends on the 

and may be irregular. portion of the heart hypertro- 

phied. 

The impulse, when present, Impulse marked if the left 

is in the third or fourth left ventricle is hypertrophied, the 
intercostal space, and is feeble. displacement is downward and 

outward, the indications are 
more in the epigastric region. 

Prognosis : — This is more serious at the ex- 
tremes of life than during mid-life; is not as dan- 
gerous in men as in women. Renal disease, 
alcoholism, exhaustion, the condition of the myocar- 
dium and valves, the nature of the underlying disease, 
all modify the prognosis, as well as the amount of 
the exudate, every extra ounce rendering the prog- 
nosis worse. When it accompanies rheumatism and 
is soon gotten rid of it is not so serious, but when 
it becomes purulent, or the hemorrhagic form ap- 
pears, it is then grave. 

Treatment: — The patient, suffering from peri- 
carditis, should have absolute rest, both mental and 
physical, in bed. The diet should be composed of 
light, easily digested solids. Too much liquid is 
injurious as it over-fills the vessels, and increases 
the arterial tension; cold applications may be used 
during the first stage but many patients cannot 
endure cold, and in these cases hot applications will 
often bring more relief. If irritants have any place 
in the treatment it is late, when the chronic condi- 
tion is present. 

Aconite: — Is indicated when the advent of the 
pericardial inflammation is attended with fever, rest- 



56 PERICARDITIS. 



lessness, anxiety and precordial pain. It may be 
indicated at any time during the disease, especially 
if the result of rheumatism and the alterations are 
not resulting in paralytic or cyanotic symptoms. 
The pulse at first is hard and strong, becoming 
feeble and soft later. Veratrum vir. is the only 
remedy that might be mistaken for aconite. In 
aconite the nervous symptoms predominate, in 
veratrum it is the circulatory. 

Bryonia alb.: — This remedy will be of service 
when pericarditis appears during pneumonia, rheu- 
matism, or pleurisy. It is during the stage of plas- 
tic exudation that it is of service rather than that 
of effusion. The thirst, aggravation from motion, 
and sharp stitching pains are characteristic. The 
patient desires to lie perfectly still. The heart's 
action is rapid and violent. The pulse is tense, 
full, and may be intermittent. 

Arsenicum alb.: — This remedy is indicated in 
the case of the cachetic individual. When such a 
remedy as veratrum vir. has been given and the 
pulse has speedily lost the characteristics of this 
remedy and a condition of marked debility has en- 
sued. There are suffocative attacks, restlessness and 
anxiety; the surface of the body is cold, and is 
relieved by warmth, there is continuous thirst for a 
little water at a time. Anguish is marked and the 
patient is apprehensive of death. Upon physical 
examination there is found to be a marked effusion 
in the pericardium. 

Digitalis purpurea: — This remedy is indicated in 
those cases where the pericardial involvement ap- 
pears slowly and unobserved, there may be no local 
pain, but there is a rapidly appearing embarrass- 



PERICARDITIS. 57 



ment of the respiration. The heart's action is 
feeble. The friction sounds are of short duration 
and the effusion is pronounced. The pulse is not 
synchronous with the heart's action; it is feeble 
and often intermittent. There is excessive feeling 
of illness, great anxiety, but no marked, or con- 
tinuous restlessness. Vomiting may appear at any 
time. Congestion of the liver and slight icterus is 
usually present. The face is livid and the lips blue. 

Spigelia: — This remedy is adapted to rheumatic 
and sero-plastic pericarditis especially if the patient 
complains of severe local pains, which are stitching 
in character and appear at any time. There is 
marked palpitation of the heart so that the chest 
wall is raised by it. The pulse is irregular. Dysp- 
nea is present and the patient can lie only on the 
right side with the shoulders raised. The least 
movement produces great suffocation, with anxiety 
and palpitation of the heart. 

Cimicifuga: — This remedy should be thought of 
when the symptoms point to involvement of the 
myocardium. The cardiac impulse is pronounced 
and irregular and can be detected over a large 
area. Percussion gives an increased area of cardiac 
dullness. The pain radiates over the left side with 
the heart as a centre, and the character of the pain 
varies, at times it is aching, again it is stinging, or 
coming in shocks. There is a headache which is 
felt most in the top of the head, as if it would fly 
off; with pain in the eyeballs. The attacks appear 
suddenly and render the patient gloomy and de- 
spondent. 

Colchicum: — Is indicated when pericarditis com- 
plicates rheumatism or Bright 's disease; the heart's 



58 PERICARDITIS. 



action is weak, intermittent and quick, with throb- 
bing of the blood vessels. There is thirst with 
coated tongue, vomiting and purging, dyspnea, and 
faintness is marked on the slightest movement. 
When colchicum does not meet the physician's ex- 
pectation Colchicine ( Merck ) 2x often does. 

Belladonna: — May be needed when the cerebral 
complications are marked. When -its well known 
indications are present. The face is flushed, the 
pupils are dilated and there is violent palpitation of 
the heart. The pulse is full, hard and tense, the 
carotids show violent throbbing. 

M Veratrum viride: — If this remedy is called for 
it is at the onset. When the heart's action is vio- 
lent, the pulse is hard, full and bounding. There is 
congestion of the lung, brain and cerebro-spinal 
system. * The patient is plethoric, of large muscular 
development and of rigid fibre. 

Kali iod: — During the stage of effusion with 
great dyspnea and excess of tough bronchial secre- 
tion. It is often of great service when absorption 
is not perfect. The iodide of ammonium should be 
studied at this period. 

Cactus grand: — There is the sensation as if the 
heart was constricted by an iron band that prevents 
its normal movement. Pains are present that are 
worse on movement of the body; he cannot lie on 
the left side. The face is blue, there is great 
dyspnea, with irregular action of the heart, the 
pulse is quick, hard and tense. 

Iodium: — When the acute symptoms have sub- 
sided, there is a distressing pain in the region of 
the heart which feels as if squeezed. A physical 



PERICARDITIS. 59 



examination shows that the exudate is not being 
absorbed. 

Sulphur: — Should be thought of when the exudate 
is not clearing up and the case is at a stand-still. 

Veratrum alb.: — Where there are symptoms of 
collapse. There is cardiac oppression, with dyspnea 
and cold sweat on the forehead. 

Naja: — This remedy should be studied when, 
after the disease is past, the myocardium shows 
evidence of having been injured. 

Paracentesis of the pericardium is demanded at 
times, not so much by the quantity of fluid present 
as by the rapidity with which effusion has taken 
place, and the danger resulting from compression 
and paralysis of the heart. When pleurisy compli- 
cates the pericarditis, tapping the pleural cavity 
may relieve the cardiac symptoms. In this proced- 
ure, as in all other surgical proceedings, absolute 
cleanliness is demanded. The instrument used should 
be sterilized. The chest wall should be washed with 
soap and water, shaven, then washed with alcohol 
and finally ether. The point selected is usually in 
the fifth intercostal space about two inches from 
the median line of the sternum. Any of the special 
instruments or an ordinary aspirating needle will 
answer the purpose. There is not much danger of 
wounding the heart if care is taken, as it is carried 
backward by the effusion until it is nearly all re- 
moved, and then it may come in contact with the 
needle. When the needle is withdrawn the punc- 
ture must be protected. A repetition of the opera- 
tion may be necessary if the effusion accumulates 
again. 

Purulent pericarditis demands a thorough open- 
ing and draining of the pericardium. 



CHAPTER VI. 

MEDIASTINO-PERICARDITIS- 

Etiology: — This usually extends from the peri- 
cardium, but cases have been recorded where the 
primary lesion was in the lungs, pleura and medias- 
tinal glands. 

Pathology : — The pericardial lesion may be 
fibrinous, serous, purulent or hemorrhagic in char- 
acter, with hypertrophy, dilatation and degeneration 
of the myocardium and various lesions of the lungs 
and pleura. A formation of bands bind the great 
vessels and base of the heart to the mediastinum, 
sternum, vertebral column and esophagus. 

Symptoms: — A most careful physical examina- 
tion and investigation of all the phenomena pre- 
sented are necessary; dropsy, cyanosis and breath- 
lessness, while present in many of these cases, are 
not of themselves sufficient to determine the char- 
acter of the difficulty. The pulse usually presents 
the characteristic known as pulsus paradoxus. The 
veins of the neck become distended during expira- 
tion. Retraction of epigastrium; systolic retraction 
of the intercostal spaces; and a fixed position of 
the apex beat have all been noticed in cases of 
this kind. 

Diagnosis : — This is not based on any one symp- 
tom but a combination of all the symptoms taken 
together. 

Prognosis: — Adhesions about the base of the 
heart and great vessels in themselves are not serious 
and the prognosis must be based on the other con- 
ditions present. 



ADHERENT PERICARDITIS. 6 1 

Treatment : — This depends wholly on the symp- 
toms presented. When pain is a marked symptom 
it may be relieved by heat. 

ADHERENT PERICARDITIS. 

The congenital absence of the pericardium 
spoken of by the older writers is now known to be 
due to pericardial adhesions. 

Etiology : — While synechia may follow any form 
of pericarditis it is most frequently met with as a 
result of fibrinous pericarditis, and that accompany- 
ing renal disease. The adhesions may form before 
the effusion takes place, or follow its absorption. 
A feeble cardiac action favors their formation. 
They are very common in those forms of pericardi- 
tis that become chronic. 

Pathology : — The degree of the adhesion varies 
from a complete synechia to the smallest possible 
band. The union is rendered possible by the fibrin 
that is deposited on the surface of the epicardium 
and pericardium during the inflammatory process. 
The adhesions are marked at the base of the heart. 
The newly formed tissue may undergo a fatty de- 
generation or calcareous infiltration. When the 
adhesions are loose and the valves normal, the heart 
is not hypertrophied, but when the adhesions are 
such as to bind the heart and the valves are defec- 
tive, there is always complete dilatation, hypertrophy, 
and later a degeneration of the myocardium. 

Symptoms: — In some cases there is nothing to 
indicate an adherent pericardium until it is revealed 
by a post mortem examination. Again, cyanosis, 
breathlessness, palpitation, edema and ascites point 
to this as the probable cause; attacks of syncope 



62 ADHERENT PERICARDITIS. 

may appear as a result late in life and angina 
pectoris is said to have been due to it. There is 
nothing about the pulse that is constant; it may be 
irregular, dicrotic, or the "pulsus paradoxicus" may 
be observed at times; there is to be seen a flatten- 
ing on each side of the apex beat, retraction of the 
left portion of the epigastrium and a drawing in of 
the intercostal spaces surrounding the apex beat. 
Careful inspection shows a defective expansion of 
the left side of the chest during inspiration, also a 
distinct collapse of the cervical veins during the 
diastole of the heart. 

Palpation reveals a diastolic rebound of the heart. 
The area of cardiac dullness depends on the pres- 
ence or absence of dilation or hypertrophy of the 
heart. Should there be no hypertrophy, the heart's 
sounds may be somewhat weakened; when hyper- 
trophy is present, they are accentuated. 

Diagnosis: — This is based not on any one symp- 
tom, but on a combination of all; the pulsus para- 
doxicus, the collapse of the cervical veins during 
cardiac diastole, the retraction of the epigastrium 
and intercostal spaces during its systole, the fixed 
position of the apex beat and heart in general, and 
the diastolic rebound form a group of symptoms 
characteristic of this disease. 

Prognosis: — Obliteration of the pericardial sac 
in itself is not serious, but when associated with 
valvular lesions there is a greater tendency to 
marked hypertrophy which soon leads to degenera- 
tion of the myocardium and heart failure. 

Treatment: — In many cases nothing is com- 
plained of and but little treatment is demanded. 
Excessive physical exertion should be avoided. The 



HEMOPERICARDIUM. '63 

diet should be such as will cause as little gastric 
derangement as possible. It is during the period of 
resolution that the remedies can be used to the 
best advantage. 

HEMOPERICARDIUM. 

This may result from direct, or indirect violence, 
or from various diseased processes. Among the 
traumatic causes are punctured wounds and tears of 
the myocardium, the result of blows or falls. Of 
the pathological causes might be mentioned rupture 
of a diseased heart from violent exercise, rupture of 
the degenerate coronary arter}' from ulceration of 
the heart, and rupture of an aneurysm. 

Pathology : — The amount of blood varies. In 
the cases where the development is rapid, the 
amount of blood is small and death is early; in 
those cases where development is slow the amount 
of blood is greater and death is delayed. 

Symptoms : — At times the symptoms all appear 
suddenly, and death is rapid. Again it may appear 
slowly. Frequently the first symptom is that of a 
sharp precordial pain or of something giving way 
which is followed by giddiness or faintness, the gid- 
diness being followed by convulsive seizure, the 
faintness by unconsciousness. A pallor is noticed 
with a cold perspiration. The pulse at once be- 
comes feeble, irregular, and empty; usually the only 
local symptom is an increased area of dullness. 

Diagnosis : — If any disease has been known to 
exist that might produce this condition, a diagnosis 
becomes much easier, otherwise its existence can 
only be determined with a degree of certainty by 
the sudden collapse and the enlarged cardiac area. 



6/\ PNEUMOPERICARDIUM. 

Prognosis: — Generally hopeless. 

Treatment: — Usually little can be done at this 
stage. The patient should be given absolute rest. 
Aspiration while it does not give much permanent 
benefit may be resorted to. Remedies should be 
selected according to the indications present. 

PNEUMOPERICARDIUM. 

Gas within the pericardium is rare. 

Etiology: — This may be due to fistulous open- 
ing, communicating with a viscera containing air. 
The discovery of the bacillus aerogenes capsulatus 
has explained the development of pneumopericardium 
in connection with traumatism. 

Pathology : — With the gas there is present an 
exudation either purulent or hemorrhagic in char- 
acter, indicating pericarditis. 

Symptoms: — These cases are attended with 
severe rigors, a high temperature and a profuse 
perspiration. Sleeplessness and delirium are com- 
mon, as well as cyanosis, edema, breathlessness, 
palpitation, syncope and pain in the cardiac region. 
The pulse is irregular and compressible, the cardiac 
impulse feeble, or absent. 

Percussion gives a tympanitic note over the car- 
diac region, the location of which varies with the 
position of the patient. 

Auscultation: — Splashing sounds are heard with 
the cardiac pulsations which are metallic in char- 
acter. Pericardial friction sounds or endocardial 
murmurs may be heard, but they are partially lost 
in the loud splashing sounds. 

Diagnosis: — This is usually easy. The tympa- 



HYDROPERICARDIUM. 65 

nitic percussion sound, varying with the position of 
the patient, and the combination of splashing and 
metallic sounds, are not met in any other disease 
to the same extent. The only condition for which 
it might be mistaken is gastric dilatation, but in 
this the upper portion of the pericardia is never 
tympanitic, and any sounds of a splashing nature 
disappear when the patient assumes the erect pos- 
ture. 

Prognosis : — This is the most serious of all 
affections involving the circulation. It is better in 
those of traumatic than in those of fistulous origin. 
In the former- the wound may heal promptly and 
the air be absorbed. While in the latter there is 
usually a septic history to start with. These cases 
do not survive long; from a few hours to two or 
three days, when death is the result of cardiac fail- 
ure, usually the result of a paralytic myocarditis. 

Treatment: — When the result of a fistulous 
opening from some other infected part, the treat- 
ment is mainly palliative unless thorough drainage 
and disinfection of the cavity can be established. 
In cases due to traumatism, antiseptic treatment 
must be instituted, that infection may not take place. 
If pericarditis appears, it must be treated on the 
general principles for that disease. 

HYDROPERICARDIUM. 

Hydropericardium or pericardial dropsy is a serous 
transudation into the pericardial sac, being similar to 
hydrothorax and ascites. 

Etiology : — Hydropericardium is a secondary af- 
fection, due to a venous stasis, the result of valvular 
disease; myocardial degeneration; or it may result 



66 HYDROPERICARDIUM. 

from disease of the lungs, pleura, kidneys, pericar- 
dium or mediastinum. 

Pathology : — The fluid in the pericardial sac is 
clear, of a greenish or yellowish tint; if blood is 
present it is reddish, or if due to broken down 
coloring matter of the blood, it is a dirty brown 
color. The specific gravity is usually about 1015. 
Epithelial and round cells, granular in character, are 
found at times. The amount of fluid varies from 
one to four thousand c. c. At a post mortem ex- 
amination the pericardium is found to be distended 
in proportion to the amount of fluid present. The 
serous surface is pale, smooth and shiny, showing 
no fibrinous exudate. If the fluid has accumulated 
slowly the pericardium is thickened, while at other 
times it is thinner than normal. The heart is gen- 
erally pale and flabby, its right side being consider- 
ably dilated. 

Symptoms: — It should be remembered that 
hydropericardium is but one phase of a great path- 
ological condition and its symptoms are often over- 
shadowed by the original disease. Its appearance 
is more frequently indicated by a sub-normal tem- 
perature than by a pyrexia. Attacks of syncope 
and dyspnea are common, while cyanosis and edema 
are present in a varying degree. If the effusion is 
marked the patient sits up, or leans forward, resting 
his elbows on his knees or on an object in front of 
him. The pulse is irregular, frequent, compressible 
and empty. The precordia may bulge and the 
intercostal space be distended. The veins of the 
neck are surcharged with blood. The cardiac 
impulse is faint if at all perceptible. The heart's 
sound and any murmur that may have been pres- 



HYDROPERICARDIUM. 67 

ent become faint. There is no friction sound. The 
liver is usually enlarged and ascites is present. The 
urine often contains albumen and is diminished in 
quantity. Edema of the lung or hydrothorax may 
be. detected at the base of the lungs. 

Diagnosis : — This is based upon the presence 
of an effusion without pericarditis and the presence 
of other diseases capable of producing it. 

Prognosis: — This depends upon the cause. If 
this is amenable to treatment it is good, if not it is 
grave. 

Treatment : — This is the treatment of the cause 
to a great extent. The use of dry foods, and the 
employment of those means that will eliminate the 
fluids from the body are beneficial. In cases where 
the symptoms appear to indicate it, paracentesis 
should be resorted to. 

Apocynum cann: — This remedy has won for 
itself the chief place in the relief of dropsical con- 
ditions. Whether they be in the form of anasarca, 
ascites, edema of the extremities, hydrothorax, or 
hydropericardium, the result of a suspended action 
of the kidneys, no structural disease being present. 
There is a sinking feeling at the pit of the stomach 
with great thirst, but water disagrees, and is vomited 
up at once. The bowels are constipated, and the 
urine is scanty and of a dark color. The dyspnea is 
so great that the patient cannot lie down and can 
scarcely speak. The best results will be obtained 
from this remedy when it is used in doses of from 
one to five drops of the tincture, or one or two 
drachms of a decoction. 

Arsenicum alb. : — This remedy should be 
thought of when there is rapid and great prostra- 



68 HYDROPERICARDIUM. 

tion, with sinking of the vital forces; marked 
anxiety and fear of death. The patient is sad and 
irritable, is much emaciated, and has a dry red 
tongue. There is great thirst; he drinks but little 
at one time, but he wants it often. The stomach 
feels distended and on fire. The nausea is accom- 
panied with great weakness, anxiety, and recurs at 
regular intervals; is worse after midnight. Ascites, 
the result of disease of the heart, liver, spleen, kid- 
neys and post-scarlatinal dropsy. There is great 
dyspnea with fear of suffocation; the patient is 
obliged to sit up. Great anguish is present. There 
are copious effusions in all the cavities. 

Apis mellifica: — When this remedy is indicated 
the pains are of a burning and stinging character, 
and urine is scanty and of high color; the face is 
swollen, pale, waxen and edematous. There is loss 
of appetite, with but little, or no thirst. It produces 
anasarca and general dropsy, with scanty urine, and 
suffocation so that the patient cannot lie down. 

Digitalis purp. : — This remedy has already been 
mentioned in several diseases; but it will be found 
of service here when there is an organic disease of 
the heart. In the earlier stages the breathing was 
only interfered with periodically; especially at night, 
while later it is continually bad, but still has par- 
oxysms. The patient cannot lie down but sits with 
the head thrown back or inclined forward. The 
jugular veins are distended, the face is livid and 
dusky, the pulse is now frequent, irregular and feeble. 
The urine is scanty and highly colored, and the 
physical examination indicates organic heart disease. 
Other remedies that might be studied with ad- 
vantage in this connection are kali carb., kali iod. r 



PERICARDIAL TUBERCULOSIS. 69 

stigmata maidis, hellebore, lycopodium, mercurius 
and sulphur. 

PERICARDIAL TUBERCULOSIS. 

This may be primary or secondary. 

Etiology: — It may be met with at any age but 
most frequently in those from twelve to thirty. It 
is more common in men than women. Primary 
tubercular pericarditis may result from an inherent 
weakness or, as in the case of young children, (nine 
months) the condition may have been present at 
birth. 

When secondary it may result from disease of 
the mediastinal glands, pleura or lungs; and probably 
some of the so-called primary causes are due to 
infected glands, or from an acute general tubercu- 
losis when the other serous membranes are involved. 

Pathology : — The exudation may be fibrinous or 
serous. The tubercular nodules are small and scat- 
tered along the course of the cardiac vessels; at 
times the tubercles are without the sac while the 
exudation and bacilli are within the sac. There is 
a great tendency to hemorrhage in all these cases; 
and a superficial ulceration of the epicardium or 
pericardium may take place. 

Symptoms: — Tubercular pericarditis may pro- 
duce no symptom by which it may be recognized 
during life, but the general symptoms of tuberculosis 
may be present; the afternoon fever, night sweats, 
emaciation, weakness and the hectic symptoms. All 
the symptoms resemble pericarditis. There is a 
tendency for it to become chronic. 

Diagnosis: — This is based on the presence of 
pericarditis and the general symptoms of tuber- 



70 PERICARDIAL SYPHILIS. 

culosis. If tubercle is present in adjacent organs, or 
when it is possible to aspirate and demonstrate the 
presence of tubercle in the fluid, the diagnosis is 
easy. 

Prognosis : — This is unfavorable. A proportion 
of the cases recover but it is small. 

Treatment : — This must be carried along general 
lines. The tendency to tuberculosis must be re- 
moved, and the general strength and nutrition 
maintained. Should the exudation be in such 
quantities as to interfere with the heart it must be 
removed. 

PERICARDIAL SYPHILIS. 

Pericardial syphilis is rare. It appears as a 
secondary or tertiary manifestation. Gumma seldom 
appears; its more common appearance being a for- 
mation of fibrous tissue, and the formation of adhe- 
sions between the pericardium and epicardium. 

Symptoms: — It has seldom been recognized dur- 
ing life. 

Diagnosis: — This depends upon the presence of 
pericarditis and the existence of syphilis in the 
system. 

Prognosis : — This is not so good as that of con- 
stitutional syphilis without the pericardium being 
involved. 

Treatment: — This requires the same general 
treatment and the use of such remedies as control 
syphilis in general. 

NEOPLASMS. 

Neoplasms of the pericardium are rare as a pri- 
mary lesion; when secondary they are more com- 



NEOPLASMS. 71 



mon when they may be found in connection with 
disease of the mediastinal glands, pleura, lungs or 
esophagus. 

Pathology : — New formations present the same 
structural peculiarities here as elsewhere; fluid in 
the pericardial sac may be serous, hemorrhagic or 
purulent. If the new growths press on the veins the 
exudation may be marked. 

Symptoms: — The detection and classification of 
these growths is impossible during life, but the 
general symptoms of pericarditis and the appearance 
of a malignant cachexia often lead us to believe 
that some malignant condition is present. 

Diagnosis: — The existence of new formations 
in other parts of the body, and the malignant 
cachexia are taken as evidence that new formations 
give rise to the symptoms. 

Prognosis : — Unfavorable. 

Treatment: — Meet the symptoms as they arise. 

ACTINOMYCOSIS AND HYDATID CYSTS. 

Actinomycosis and hydatid cysts are among the 
rare affections of the pericardium. 



CHAPTER VII. 
MYOCARDITIS. 

This is an inflammation involving the muscular 
structure of the heart, it may be acute or chronic. 

ACUTE. 

Acute myocarditis is most frequently found asso- 
ciated with endocarditis or pericarditis. The rheu- 
matic form of myocarditis may exist apart from 
either endo- or pericarditis, and it may be met with 
during an acute infectious fever or from an infec- 
tious embolism. 

Pathology : — This varies according as the paren- 
chyma or interstitial tissue is first involved; and 
whether the disturbance is general or localized. 

In the acute parenchymatous variety there is a 
granular degeneration of the muscular fibres of the 
parenchyma, with a numerical increase of their 
nuclei. The muscular structure is soft, turbid, and 
looks pale. In the diffused interstitial variety, the 
primary changes are in the connective tissue and 
consists of an infiltration of round cells. 

In the localized variety, the changes result in 
the formation of an abscess or abscesses, which in 
time discharge into the pericardium or into one of 
the cardiac chambers. When the discharge is into 
the blood current, the infection is carried to various 
parts of the body and the embolism establishes an 
abscess. The parts weakened by the abscess may 
give rise to rupture of the heart or an aneurysmal 
dilatation. 

Symptoms : — These are not positive. The pulse 



ACUTE MYOCARDITIS. 73 

is irregular, small, rapid aud compressible. There 
are repeated attacks of cardiac palpitation, enfeeble- 
ment and syncope. Later, venous stasis appears. 
When a patient suffering with rheumatism, septi- 
cemia or disease that may produce this affection, 
produces this group of symptoms, myocarditis should 
be thought of. 

Physical Signs: — During the early stages there 
may be no physical evidence to indicate any such 
trouble. When they appear they are such as indi- 
cate a progressive chronic dilatation. There is an in- 
creased area of dullness with displacement of the apex 
beat downward and outward, with weakening of the 
first sound; on account of the diseased condition of 
the myocardium the valves do not perform their work 
perfectly and as a result murmurs appear. A cir- 
cumscribed increase of cardiac dullness with pulsa- 
tion in a particular direction (upward and toward 
the left), should make one think of cardiac 
aneurysm; an embolic process with cardiac murmur 
and a septic type of fever should lead to a careful 
investigation for circumscribed myocarditis. 

Diagnosis: — The myocardium is involved in 
every case of rheumatic endocarditis or pericarditis. 
Typhoid fever and variola at times give rise to 
myocarditis without the endocardium being involved. 
It is impossible to make a positive diagnosis of 
myocarditis in the majority of cases; but when a 
cardiac weakness appears with greater rapidity than 
in acute degeneration, and less so than in rupture, 
myocarditis is to be expected. 

Prognosis : — This depends on the extent to which 
the myocardium is injured by the inflammation, as 
muscular fibres that have been replaced by fibrous 



74 ACUTE MYOCARDITIS. 

tissue leave the heart wall weakened, rendering it 
liable to rupture during severe exertions. Of the 
various forms, the diffused is most fatal, recovery 
may take place from the circumscribed variety that 
accompanies rheumatism. 

• Treatment : — When myocarditis appears as the 
result of some other disease, the treatment of the 
original disease must be the guide. In all cases 
absolute rest must be insisted upon and nutrition 
maintained. 

Stimulants : — Aromatic spirits of ammonia, ten to 
fifteen drops every hour, in glycerine, assists many 
of these cases by preventing the blood from remain- 
ing in the heart. Alcohol should not be used in 
this class of cases or quinine, as they are both vaso- 
motor paralyzers. The heart tonics have no place 
in the treatment of myocarditis. This disease must 
be treated symptomatically and those remedies that 
are known to have a disorganizing action must be 
studied. 

Aconite will be found serviceable when heart 
failure is impending. 

Arsenicum album: — This remedy should be 
studied when there is great prostration with rapid 
sinking of all the vital forces, with mental anguish 
which increases as the suffering increases, and is 
attended with restlessness and fear of death. The 
restlessness is marked, but the patient is physically 
too weak to move. He believes that he is going 
to die, that his disease is incurable and it is useless 
to take medicine. The pains are burning in char- 
acter; the affected parts burn like fire; and relief 
comes from heat, hot applications and hot drinks. 
There is srreat thirst for cold water, of which he 



ACUTE MYOCARDITIS. 75 

drinks often, but little at a time; after eating or 
drinking there is diarrhea, the stool being dark, 
offensive, and followed by great prostration. There 
is rapid emaciation, with cold sweats, pale skin 
and great exhaustion, which the patient notices 
most when he attempts to move. The patient is 
worse from i to 2 p. m. and 12 to 2 a. m. 

Muriatic acid: — This remedy is most frequently 
indicated in those patients that have dark complex- 
ion, hair and eyes; are peevish, irritable and dis- 
posed to anger and chagrin. There is great pros- 
tration so that the patient slides down in bed; the 
lower jaw drops and the eyes close the minute he 
sits or lies down. There is ulceration about the 
mouth and anus, the tongue and sphincter ani being 
paralyzed. There is involuntary stool and urination, 
and he cannot urinate without the bowels moving. 
The patient is in a deep, stupid sleep; is uncon- 
scious while awake; the tongue is coated at the 
edges, and is shrunken, dry and leather like. The 
pulse intermits every third beat. 

Lachesis : — With this remedy there is great 
physical and mental exhaustion with trembling in 
the whole body. There is a hemorrhagic diathesis, 
so that small wounds bleed easily and profusely, 
the blood being dark and non-coagulable. The 
patient is in a stupor, the countenance is sunken, 
the lower jaw drops, the tongue is black, dry and 
trembles so that it catches the teeth when being 
protruded. The conjunctiva is yellow, or orange 
color. The perspiration is cold and stains the 
clothing yellow. There is great hyperesthesia of 
the skin, especially about the neck and waist, and 



76 CHRONIC MYOCARDITIS. 

all symptoms are worse from sleep and on the 
left side. It is best adapted to thin individuals. 

Crotalus horr: — There is great prostration of the 
vital forces; there is a bloody sweat, the blood 
flowing from all the orifices of the body. The 
patient is suffering from a low state of the sys- 
tem; the vital forces are exhausted. The tongue 
is fiery red as if polished. The skin is cold and 
dry; the expectoration is black blood. 

Phosphorus: — This remedy is demanded at times 
by those who are tall and slender, with a fair 
skin t delicate eyelashes; and in young people who 
have grown too rapidly and are over-sensitive to 
all external impressions. There is hemorrhagic 
diathesis with a weak, gone sensation in the entire 
abdomen. As soon as water becomes warm it is 
vomited. If constipation be present, the stool is 
long, dry and hard; if there be diarrhea, it is 
profuse, pouring away from the patient as from a 
hydrant. The patient is worse before midnight 
and while lying on the left side. 

CHRONIC MYOCARDITIS OR FIBROUS CHANGES OF THE 
HEART WALL. 

This is a chronic inflammation of the myocar- 
dium, in which there is either a hyperplasia of 
the connective tissue or a substitution of fibrous 
for muscular tissue. 

Etiology : — This is a disease of advanced life in 
which more males than females are affected, and 
a hereditary tendency prevails in certain families. 
The principal causes are alcohol, tobacco, syphilis, 
malaria, diabetes, rheumatism, gout, chronic neph- 



CHRONIC MYOCARDITIS. 77 

ritis, lead poisoning, lithemia, adherent pericard- 
ium, chronic vascular changes and valvular diseases; 
or it may be an extension of the inflammatory 
process from a chronic peri- or endocarditis. 

Pathology : — This is as varied as the causes. 
The structural changes during adult life are found 
in the wall of the left ventricle, the septum and 
the papillary muscles. The wall of the right 
ventricle is the one involved during fetal life. 
There is an increase in the size and weight of the 
organ and it shows both dilatation and hypertro- 
phy. The portion of the heart wall affected is 
paler and thinner than the healthy part, and is 
harder to the feel. The lumen of the coronary 
arteries, especially the left, is contracted, either 
by endarteritis or atheroma, obliterating its orifice. 
Frequently the whole arterial tree shows sclerosis, 
with a general increase of the fibrous tissue 
throughout the body, and cirrhosis of the kidney. 
The microscope shows a degeneration of the muscu- 
lar fibres with an increase of the fibrous tissue. 
Muscular cells are seen in different degrees of disin- 
tegration, from granular to fatty cells and fibrous 
tissue replacing the muscular. When the lumen 
of a sclerosed vessel is occluded by a thrombosis, 
the part supplied by the artery loses its normal 
color and becomes soft, of a pale brown or yellow 
color, the striae disappear and the muscular fibres 
have a hyaline appearance. 

Symptoms: — The symptoms vary according to 
the etiology. Many patients complain of palpita- 
tion, fluttering of the heart, throbbing of the arte- 
ries, attacks of breathlessness which are accom- 
panied by giddiness and faintness. Pain is com- 



78 CHRONIC MYOCARDITIS. 

plained of, which varies from a mere sense of 
disturbance to the most agonizing attack of angina 
pectoris. The temporal artery may be tortuous 
and the arteries in general hard to the feel, with 
indications of degeneration. In the early stage 
the pulse may be of high tension, regular and 
full. When cardiac failure appears, the tension is 
low, the vessel empty, and the rythm irregular. 
The apex beat is displaced downward and to the 
left. 

Percussion: — Shows the area of cardiac dullness 
increased. 

Auscultation: — Shows the second aortic sound 
increased and doubled, while the first mitral sound 
is of a lower pitch than normal and may be re- 
placed by a murmur. Cheyne-Stokes respiration 
is a frequent symptom whenever the patient sleeps, 
as is dyspnea from exertion. The urine is dimin- 
ished in quantity, is of high specific gravity, and 
in many cases contains albumen. Cerebral derange- 
ment in the form of sleeplessness, loss of memory, 
and anxiety often appears. This disease may be 
slow in its course, or may terminate life suddenly. 

Diagnosis: — This is not an easy matter. The 
similarity of fatty degeneration and chronic myo- 
carditis renders it difficult to differentiate them. 
The symptoms of arterial degeneration; the vigor- 
ous cardiac impulse; the accentuated, second aortic 
sound and cardiac pain; all point to a degeneration 
of the myocardium rather than a fatty degenera- 
tion. 

Prognosis. — The history of the case, whether of 
slow or of rapid development; the condition of the 
cardiac impulse, and the first sound are important; 



CHRONIC MYOCARDITIS. 79 

as well as the effect of muscular exertions, such 
as walking up stairs; denote the condition of the 
myocardium; attacks of syncope and angina pec- 
toris in connection with degeneration of the myo- 
cardium are unfavorable omens. 

Treatment. — All the habits of the patient must 
be carefully studied and regulated. Massage will 
be of benefit. The Nauheim baths are of great 
service. The etiology should be studied carefully 
and any dyscrasia that may be present in the 
system, corrected. If the dyscrasia is due to 
syphilis, the mercurials or iodides will be found of 
service, as indicated; also, gold in some form, or 
the chloride of gold and sodium. When the de- 
generation is a family characteristic, the iodide of 
arsenic will be of benefit. The so called heart 
tonics are usually injurious to such a heart; at 
times, the strychnia arsen., strychnia phos., caffeine 
and digitalis are indicated. The more the heart is 
rested and nourished, the better. Where there is 
an inherited tendency to such changes, the deeper 
acting remedies as sulphur, psorinum, syphilinum 
should be studied. There should be a degree of 
exercise; but the heart should be given all the 
rest possible. *The diet should be highly nutritious 
at all times, and easily digested. 



CHAPTER VIII. 
ACUTE CARDIAC DILATATION. 

This is an acute dilatation of one or more of 
the cavities of the heart. 

Etiology: — It is produced by a sudden increase 
of the intra -cardiac blood pressure, which may re- 
sult from a severe muscular effort; as mountain 
climbing, heavy lifting, athletic feats and bicycling 
in those who have not been training for such 
tasks. Depressing mental emotions are frequent 
causes. Predisposing causes may be at work in 
the form of myocardial degenerations. In those 
suffering from diphtheria and typhoid fever, dilata- 
tion and death, at times, follow the assuming of 
the erect or sitting posture; this has also been 
observed during pneumonia. A rupture of an 
aortic cusp may produce similar symptoms. 

Pathology : — The wall of the part affected is 
thinned and the cavity is partially filled with 
coagulated blood. The obstruction is most fre- 
quently in the pulmonary circulation, and the right 
side of the heart being thin is most frequently 
dilated; when the systemic arteries are at fault, 
the left side of the heart dilates. 

Symptoms: — There is a history of some sudden 
or violent action that the patient is not adapted 
to. The onset is rapid, the heart's action is 
quickened; the respirations are accelerated at first, 
then breathlessness follows; the individual becomes 
dizzy and nauseated; the pulse is small; the 
skin becomes a gray ashen color; the lips are 
purple; the vision becomes clouded; the mind fails; 



ACUTE CARDIAC DILATATION. 8 1 

and the man falls. If dilatation has not been 
marked, the individual may recover after a few 
days; if more pronounced, he may die; or if 
recovery takes place, it is slow, requiring months 
and years to regain a normal condition. 

Physical Signs: — The cardiac impulse is weak 
and fluttering. The area of cardiac dullness is 
increased to the right or left of the sternum, 
according as the right or left side of the heart is 
involved. The heart sounds are rapid and indis- 
tinct. 

Diagnosis: — There is usually a history of pro- 
longed or extreme physical exertion, with the 
appearance of • circulatory disturbance. The great 
dyspnea, the heart's irregular action, and mental 
disturbance are prominent symptoms; together 
with those observed during physical examination. 
The area of cardiac dullness is usually more 
marked, especially to the right. Should the trou- 
ble be due to the rupture of an aortic cusp, a dias- 
tolic murmur is heard; at times it is necessary to 
wait some time, until the heart has had rest, 
before stating how extensive the dilatation is. 

Prognosis : — At times, death follows the dilata- 
tion at once; in other cases, a compensatory hyper- 
trophy is established and life is prolonged; but if 
this hypertrophy is not established, death comes 
later. In these cases the effect of rest must be 
studied and the prognosis based upon it. 

Treatment : — The first requirement is absolute 
rest. This should be in bed and free from all 
forms of annoyance. Cold applications over the 
precordia often brings a degree of relief to the 



82 CHRONIC CARDIAC DILATATION. 

patient. The cause if still active, should be re- 
moved. The diet should be nutritious but as dry 
as possible. Four or five medium sized meals 
being preferable to three large ones. 

Arnica mont. : — This remedy is frequently indi- 
cated after injuries, strain and in the over-exertion 
of athletes. There are bruised pains in the chest 
with a sense of compression and palpitation. Pain- 
ful pricking in the heart, fainting fits, and cough 
with expectoration of blood. 

Laurocerasus: — Whenever a little exercise pro- 
duces cyanosis with gasping for breath, this remedy 
should be studied. There are spasmodic contrac- 
tions of the throat and chest with great dyspnea, 
slow irregular pulse with fluttering in the region 
of the heart, and gasping for breath, with cough. 

Convallaria: — This remedy has proven itself 
serviceable in certain cases of dilatation of the 
right side of the heart, not during the very acute 
stage but later in the case. 

Ignatia: — When the dilatation is the result of 
depressing mental emotion and grief, this remedy 
is indicated. 

Arsenicum alb. : — This remedy will benefit those 
cases that result from mountain climbing. 

After the acute symptoms subside, any of the 
cardiac remedies may be indicated. 

CHRONIC DILATATION OF THE HEART. 

This is an enlargement of one or more of the 
cavities of the heart. 

Etiology /—Of the predisposing causes, heredity 
is the most fruitful. Not only is there a tendency 



CHRONIC CARDIAC DILATATION. 83 

in certain families to degeneration of the cardiac 
muscle, but also, to those diseases that favor its 
development and terminate in dilatation. On 
account of their work and modes of life, it is 
found more frequently in males than females. 
Toxic conditions whether from a necrotic origin or 
the result of renal disease, is attended with dila- 
tation, as are anemic and cachetic states, the 
result of improper food and bad hygienic sur- 
roundings. Degeneration of the myocardium and 
coronary arteries, and an adherent pericardium 
form a group of predisposing symptoms connected 
with the heart itself. Of the exciting causes, is 
an extra amount of blood within the heart and as 
a result, an increase of the intra cardiac blood 
pressure with a diminution of the resisting power 
of the heart. Of the more chronic conditions that 
give rise to dilatation, are chronic valvular dis- 
eases. Emphysema and other pulmonary diseases 
produce dilatation of the right side of the heart; 
while diseases involving the systemic arteries pro- 
duce dilatation of the left side. 

Pathology : — Dilatation may be general or par- 
tial. If one cavity suffers much, the whole organ 
will be dilated to a certain degree. 

In simple dilatation the weight of the heart is 
not materially increased. If the dilatation be gen- 
eral, the heart will be rounded in shape and its 
breadth increased. When the right ventricle alone 
is dilated the breadth of the heart is increased; 
if the left ventricle too is affected, the heart is also 
lengthened. The auricles are more frequently 
dilated than the ventricles, and the right ventricle 
more than the left. In case .of aortic stenosis 



84 CHRONIC CARDIAC DILATATION. 

there is little dilatation, but marked hypertrophy 
of the left ventricle; while in incompetency of this 
orifice there is great dilatation with marked hyper- 
trophy. In stenosis of the mitral orifice there is 
marked hypertrophy of the left auricle with but 
little dilatation, while in incompetency there is 
great dilatation. 

Following disease of the mitral valve and lungs, 
the right ventricle is affected. 

The auriculo-ventricular orifice may dilate as 
the result of the dilatation of the cardiac cavities 
and render the cusps incompetent. When dilatation 
becomes pronounced, the trabecular are stretched 
and cord-like. A regurgitant murmur indicates that 
hypertrophy is no longer capable of rendering per- 
fect compensation, as the papillary attachment of 
the chordae tendinea is displaced from the centre 
of the ventricle, and the perfect closure of the 
auriculo-ventricular orifice is prevented. 

Symptoms : — The symptoms of chronic dilatation 
appear slowly. There is a gradual loss of strength, 
and a feeling of faintness is complained of on any 
exertion of importance. Frequently the gastric 
function is deranged to such an extent that the 
patient complains of nothing else. The area of 
hepatic dullness is increased and jaundice may be 
present. Ascites is present in the majority of 
cases to a varying degree. As compensation be- 
gins to fail, cardiac palpitation appears with a 
feeling of uneasiness or pain in the cardiac region; 
the cardiac rythm is irregular. The pulse is rapid 
but weak, and the arterial tension is low; at times 
the radial pulse will appear slow, but upon exam- 
ination it will be found that there is an absence 



CHRONIC CARDIAC DILATATION. 85 

of every other beat. Dyspnea appears gradually 
and is preceded by fine moist rales in the lower 
portion of the lung; most marked in the left, and 
soon the patient is obliged to sit up all the time. 
When there is dilatation of the right heart, the 
patient frequently complains of a distress in the 
epigastric region when bending forward. 

Physical Signs: — Inspection shows the apex 
beat so diffused that it is impossible to locate it. 
When the right ventricle is dilated the cardiac 
impulse is prominent in the epigastric region; 
the jugular veins may be varicosed and pulsating. 

Palpation. — This reveals a heaving, diffused 
cardiac impulse; and the apex beat is carried to 
the . left and diffused. The apex beat is carried to 
the left in simple dilatation, and to the left down- 
ward if hypertrophy be present. 

Percussion: — Outlines an enlarged area of car- 
diac dullness. If the right ventricle is most in- 
volved, the dullness may extend to the right 
nipple. When the left side is affected, it may 
extend to the left axillary line. When the 
auricles are involved the dullness may extend to 
the first rib. 

Auscultation: — Reveals the heart's sounds to be 
feeble and indistinct. The first sound is weak, 
muffled, and may not be heard. The second is 
more pronounced except at the apex. A systolic 
murmur may be present if there is marked dila- 
tation. 

The impaired percussion sound, the roughened 
respiratory murmur, and moist rales of the lungs, 
indicate a passive hyperemia. There may be 



86 CHRONIC CARDIAC DILATATION. 

edema of the lungs or an effusion into the pleural 
sac. The urine is lessened in quantity, the solids 
are increased, and albumen and blood may be 
present. 

Diagnosis: — This is based on the increased 
area of cardiac dullness, the weak, irregular heart 
action and diffused indistinct apex beat; the feeble 
first sound; the dyspnea; cyanosis; edema and the 
distended condition of the veins. 

DIFFERENTIAL DIAGNOSIS. 
DILATATION OF THE HEART. CARDIAC HYPERTROPHY. 

Pulse. 
Small, vigorless, irregular Full, sustained and regular, 

and intermittent. 

Area of Cardiac Dullness. 
Increased upward and out- Increased outward and 

ward. downward. 

Cardiac Sound. 
Brief, sharp, feeble first Prolonged, dull first, and 

sound, second is enfeebled. accentuated second sound. 

Heart Action. 
Weak and irregular, with Slow but heavy impulse, 

an extended, wavy impulse. 

Apex Beat. 
Diffused and weak. Strong. 

Prognosis : — This is unfavorable; while the dis- 
ease may be stayed for a time, sooner or later it 
becomes progressive. The nutrition of the patient 
modifies the prognosis, as the condition of the 
heart is dependent upon it. The primary cause of 
the dilatation must always be taken into considera- 
tion. So long as the heart's action is regular under 



CHRONIC CARDIAC DILATATION. 87 

normal conditions the immediate prognosis is not 
bad; but when it becomes irregular at all times, 
with indications of venous congestion as indicated 
by dyspnea, anasarca, gastric and renal disturb- 
ance; the prognosis is bad and the chances are 
that the patient will not survive a year. 

Treatment : — The treatment of chronic dilatation 
of the heart embraces all those measures that are 
employed for the relief of a failing heart; and 
the diseases that cause it. Each case must be 
studied in its totality and treated accordingly, as 
no routine treatment will benefit. These cases 
demand a prolonged absolute rest in bed; it will 
be found that the annoying symptoms, as dyspnea, 
cough, cyanosis and dropsy, disappear quicker when 
this is insisted upon. The nutrition must be main- 
tained and as a result, a proper diet is of import- 
ance. This should be nourishing and easily assim- 
ilated. Liquors should form no part of the diet; 
if any is allowed, it should be light dry wine; 
whiskey and brandy are injurious. An intelligent 
use of exercise benefits the majority of these 
cases; the idea being to establish an equilibrium 
so far as is possible, between the dynamic power of 
the heart and the resistance against which it 
labors. To this end massage, walking and moun- 
tain climbing have been employed; of late the 
method mostly employed has been Schott's, which 
consists in resistance exercise and medicated baths. 

Digitalis: — When this remedy is indicated the 
heart's action is weak, the contractions lack vigor; 
as a result, the arteries are empty and the veins 
distended. The pulse is weak, intermittent and 
irregular. There is oppressed breathing with a 



88 CHRONIC CARDIAC DILATATION. 



feeling of anxiety in the cardiac region, the patient 
cannot fill his lungs and desires more air; he com- 
plains of a sinking and weak feeling in the epigas- 
tric region. The least movement produces violent 
palpitation and there is a sensation as if the heart 
would stop beating if he moved, with fear of im- 
pending death. 

Convallaria: — This remedy is indicated when 
there is valvular disease, either stenosis or insuffi- 
ciency; the ventricles are suffering as a result and 
dilatation is taking place; compensation is failing, 
there is venous congestions and a deficiency of 
arterial blood, The least exertion produces pal- 
pitation of the heart. The mental condition is 
one of great irritability. 

Strophanthus hisp. : — This remedy is indicated 
when the heart's action is rapid and feeble; as the 
pulse becomes stronger there is relief of the 
dyspnea. It should be studied when digitalis dis- 
turbs the digestive organs or does not yield favor- 
able results. 

Crataegus oxyacantha: — This remedy in five- 
drop doses of the tincture will often bring excel- 
lent results. 

Calcarea hypophos. : — When the general nutri- 
tion is below the normal, especially in the young, 
this remedy, in connection with a nourishing diet, 
has often given good results. There is depression 
of spirits with an emaciated, pale face: appetite 
and digestion is poor. Inspection may show a 
chicken breast or spinal curvature with anemia. 
The blood vessels of the hands and feet are dis- 
tended and the extremities are habitually cold. 






CHRONIC CARDIAC DILATATION. 89 

Sparteine sulph. ix. : — This remedy is indicated 
in patients who are nervous and hysterical, with 
great muscular weakness. The heart's action is 
weak and feeble. The pulse is weak and small. 
There is more or less dropsy present that is re- 
moved under the influence of this remedy. 

Agaricine ix. : — In those patients who have 
been addicted to the excessive use of tea, coffee or 
tobacco, or are recovering from some debilitating 
disease that has greatly weakened the heart; the 
pulse is weak and irregular, while the heart's 
action is weak and attended at times by violent 
palpitations. There is profuse sweating with 
twitching of the muscles and dilatation of the 
heart. 



CHAPTER IX. 

CARDIAC HYPERTROPHY. 

Definition: — This is an enlargement of the heart 
due to an increase in the volume of the muscular 
fibres. 

It exists under two different forms, in one there 
is a simple hypertrophy without any change in the 
size of the cavities of the heart; while in the second 
there is a dilatation of these cavities. 

Etiology: — It is a conservative process estab- 
lished as a result of interference with, or defect in 
the vascular system. Among the causes are inter- 
ference with the circulation of the blood through 
the small arteries, due to certain toxic agents; as 
the result of Bright's disease, syphilis, gout or lead 
poisoning; obliteration, narrowing or inelasticity of 
the walls of the blood vessels, as found in the aged; 
general arterial sclerosis, hydremic plethora and 
narrowing of the aorta, whether from congenital or 
other causes; emphysema and pleuritic effusion are 
the principal pulmonary causes. Any defect in the 
circulation of the blood in the heart that demands 
an extra effort on the part of the heart muscle, is 
sure to be attended by more or less hypertrophy. 
The form known as "primary idiopathic" is de- 
pendent on prolonged physical exertion. Neuroses, 
tea, coffee and alcohol are all responsible for a 
percentage of these cases. 

Pathology : — The hypertrophy may be general 
or partial. While any part of the heart may be 
hypertrophied, the left ventricle is more frequently 
involved than the right, and the right auricle more 



CARDIAC HYPERTROPHY. 9 1 

frequently than the left, this being in proportion to 
their physiological importance. The shape of the 
hypertrophied organ is dependent on the part or 
parts involved. Whenever dilatation is associated 
with the hypertrophy the organ is greatly enlarged. 
The papillary muscle, the columnar carnse and the 
muscular trabecular are all greatly thickened, the 
latter especially in the right side of the heart. The 
muscular tissue is a deeper red and firmer; as the 
heart enlarges it sinks lower in the chest owing to 
increased weight and size. The hypertrophy is due 
to an increase in the muscular fibres. 

Symptoms : — So long as the compensation is per- 
fect there are no symptoms; but the patient early 
recognizes that the fine adjustments between the 
circulation and the condition imposed on it are 
easily disturbed from slight emotion or exercise. 
The pulse is full, strong and of high tension. A 
dry, irritating cough is often complained of. The 
pronounced cerebral circulation may give rise to 
headache, tinnitus aurium, carotid pulsation, flashes 
of light before the eyes and flushed face. 

The physical signs vary according to the part 
of the heart involved. 

Inspection: Shows the force of the apex beat to 
be increased, lower than normal and to the left; 
and cardiac area to be enlarged. When the right 
side is more involved there is epigastric pulsation 
and the apex beat, while to the left, is not lowered 
to the same extent as is found when the left side 
is involved. 

Palpation: — This confirms inspection and there 
is bulging of the precordial region and the pulse is 
full and forcible. 



CARDIAC HYPERTROPHY. 



Percussion: — Shows the area of cardiac dullness 
to be increased both vertically and transversely. 

Auscultation : — Is not reliable, as the heart sounds 
are modified more by the condition of the myocar- 
dium than by the hypertrophy. If the hypertrophy 
is well advanced and the heart muscle is in a nor- 
mal condition the first sound will be dull, prolonged 
and booming. Should the myocardium be below 
par, the first sound may be hardly noticeable, and 
the intensity of the second sound depends on the 
arterial tension. 

Diagnosis: — The Cardinal points in the diagno- 
sis are the displacement of the apex beat to the 
left, the heaving, forcible impulse, and the increased 
area of cardiac dullness. This last symptom must 
not be confounded with pericardial effusions, aneu- 
rysm, mediastinal growths, displacement of the 
heart, left-side pleurisy, phthisis and cirrhosis of 
the lungs. Cardiac hypertrophy, unlike tumor 
formation, is a perfect reproduction of the original 
tissue, having the same function, and it occurs only 
when the muscle is healthy and properly nourished. 
The hypertrophy is not in itself dangerous, the 
danger being in the subsequent dilatation which is 
slowly brought about, owing to changes in the 
coronary arteries or a general malnutrition. 

Prognosis : — Several questions must be carefully 
considered before the prognosis is stated: ist, are 
the nutritive possibilities such as will allow a suffi- 
cient hypertrophy to compensate for the original 
lesion ? 2d, Does the nature of the primary lesion 
permit a sufficient hypertrophy to compensate ? If 
the cause is removable and the hypertrophy full, 
the prognosis is good. If the cause is one that 



CARDIAC HYPERTROPHY. 



93 



cannot be removed the prognosis is good so long 
as compensation is full. But if the cause is pro- 
gressive there will come a time when the compen- 
sation will not be sufficient and the prognosis is 
then unfavorable. 

Treatment : — The treatment of cardiac hyper- 
trophy resolves itself into the maintenance of a 
necessary hypertrophy. If the cause of hypertrophy 
is amenable to treatment it should be removed. 
Such cases are usually due to over-exertion or have 
nervous or toxic origin. Hygiene and dietetics are 
especially useful in this class of cases. All the func- 
tions of the body should be kept in as perfect a condi- 
tion as possible. The diet should be carefully regu- 
lated as to quantity and qualit} T , as over-eating is espe- 
cially injurious; and the less liquid taken the better, 
so long as the normal physiological conditions are 
met. If the patient is in the habit of using tea, 
coffee or liquor, their action on the heart should be 
studied carefully, and if they are found to be in- 
jurious they should be dropped from the bill of 
fare. The patient should avoid being fatigued. 
Gentle exercise is the best method of keeping up 
the normal muscular tone and vigor. Violent exer- 
cise should not be allowed under any circumstances. 
The cutaneous circulation should be stimulated either 
by the flesh-brush or by the cold sponge bath, fol- 
lowed by thorough friction. The mental condition 
of the patient should be as cheerful as possible; he 
should have plenty of sleep and have but a light 
meal before retiring. Woolen clothing should be 
worn uext to the skin the year round. If, in spite 
of the regulation of the patient's habits there are 
decided symptoms pointing to a gradual loss of com- 



94 CARDIAC HYPERTROPHY. 

pensation, absolute rest in bed must be insisted 
upon, that the work of the heart may be dimin- 
ished and allowed to regain its disturbed compensa- 
tion. To this class of patients, when there is ground 
for it, a favorable opinion, confidently expressed, is 
often of benefit. 

Aconite is indicated when there is palpitation 
with marked anxiety and restlessness, in robust, 
strong, full blooded individuals. There is glistening 
of the eyes and injection of the conjunctiva. 

Adonis vernalis has recently assisted in establish- 
ing a compensatory hypertrophy in two cases, one 
of aortic stenosis and the other of mitral regurgita- 
tion. The symptoms were edema of the lower 
extremities, great dyspnea, scanty urine and irregu- 
lar pulse. 

Arsenicum alb. is of service when the muscular 
structure of the heart is involved. There is palpi- 
tation of the heart and general anasarca; the pulse 
is small and irregular. The characteristic restless- 
ness, anxiety, prostration, thirst and nightly aggra- 
vations are present. This remedy has also been 
of service in those cases that develop as the result 
of mountain climbing. 

Arnica montana has not been of much service 
in hypertrophy of the heart, but in cases where the 
heart has been put upon a strain that it had not 
been prepared for, such as violent running, bicycl- 
ing, etc., it is of service. There is distress in the 
cardiac region, with a slow pulse while at rest, 
which becomes rapid on motion. 

Convallaria majalis is indicated when the right 
side of the heart is involved, as the result of ob- 



CARDIAC HYPERTROPHY. 95 

struction to the pulmonary circulation. The heart's 
action is weak; there is great dyspnea with faintness 
and palpitation of the heart. 

Cactus grandinora has been so frequently veri- 
fied that it needs only to be mentioned. There is 
hypertrophy with dilatation, the patient is pulseless 
and extremely exhausted, cannot lie down, has sen- 
sation of constriction about the heart, as if an iron 
prevented its normal movement; acute pains and 
painful stitches in the heart with obstruction to the 
respiration. 

Collinsonia Canadensis was found useful in one 
case where the heart was greatly hypertrophied 
and there was palpitation and pain. • This remedy 
controlled the difficulty, the guiding symptom being 
the hemorrhoids and constipation. 

Crataegus is a remedy I have used several times 
with success, especially where there was a failure 
of the normal action of the heart; but I am unable 
to define its action with certainty. 

Digitalis is a valuable but much abused remedy. 
Its characteristic, to my mind, is an extremely slow 
pulse becoming accelerated and irregular on the 
patient assuming a sitting posture or on the least 
movement. There is edema about the ankles, 
dyspnea and cyanosis. He feels that the heart 
would stop if he moved. 

Iodide of arsenic has been of great service in 
maintaining compensation in the aged. There is 
palpitation of the heart with hypertrophy, and 
tightness across the chest. An examination of the 
arteries shows that you are dealing with an arterial 
as well as a cardiac degeneration. 



96 CARDIAC HYPERTROPHY. 

In kalmia latifolia there are paraoxysms of pain 
about the heart with dyspnea and febrile excitement; 
there is endocarditis with wandering rheumatic 
pains in the region of the heart, extending down 
the left arm, and palpitation which is worse while 
the patient is lying on the left side, but relieved by 
lying on the back. 

Lycopus Virginicus has been of service in several 
cases of failing compensatory hypertrophy. One 
case especially was that of a man seventy years old 
who was addicted to the use of tobacco and had 
used a great deal of alcohol. There was an endo- 
cardial murmur, and rapid dilatation of the heart 
was taking place. A cough with hemoptysis was 
present, and the heart's action was quick, irregular 
and feeble. 

Naja tripudians has rendered valuable service 
when there was present an annoying sympathetic 
cough with exaggerated heart action. The heart is 
increased in size and there are organic changes of 
the valves. There is dyspnea and prostration with 
marked pain about the heart and general anasarca. 

Sparteine sulphate has been of special service in 
hysterical subjects with a neurotic history, when the 
heart muscle appears to be undergoing degeneration 
and compensation is failing. 

Veratrum viride has many of the symptoms of 
aconite, but here there is less disturbance of the 
nervous system and more of the arterial; as indi- 
cated by the more forcible action of the heart, the 
strong pulse, and greater congestion of the head 
and chest. 



CHAPTER X. 

FATTY HEART. 

Definition: — Fatty heart is a term used to 
designate two widely different pathological condi- 
tions. In one there is an excess of fat on the sur- 
face and between the muscular fibres of the heart 
and it is known as fatty accumulation with infiltra- 
tion; in the other, fat has taken the place of the 
muscular fibres and it is known as fatty degenera- 
tion. 

FATTY ACCUMULATION WITH INFILTRATION. 

Etiology: — This is dependent upon those causes 
that give rise to obesity, and is seldom met with 
in thin individuals. In some of these cases there 
is a hereditary tendency to obesity; while in others 
there is a congenital small lung, and as a result, 
deficient oxygenating capacity. Want of exercise, 
lack of fresh air, and improper expansion of the 
lungs are occasional causes; but the greater number 
of cases are dependent on excessive indulgence in 
food, especially saccharine and amylaceous articles 
of diet, as sweet wines, porter, beer, alcohol, starch, 
sugar and fat;, and are also dependent on the 
defective metabolism of nitrogenous foods. It is 
seldom found in individuals before thirty, and more 
frequently after fifty years of age. Four cases are 
met with in males to one in females. 

Pathology : — There is a certain amount of fat 
about every normal heart, found in the grooves be- 
tween the auricles and ventricles, and between 
the ventricles themselves; but in cases of fatty accu- 



98 FATTY ACCUMULATION. 

mulation, it covers especially the right ventricle and 
finally the whole heart is enveloped; meanwhile the 
fat is passing along the intermuscular septum, giving 
rise to fatty infiltration, which, encroaching upon 
the myocardium, terminates ultimately in fatty de- 
generation. 

Symptoms : — Some of these cases do not complain 
of any inconvenience. The symptoms, when present, 
are those indicating interference with the cardiac 
function; as indicated by the sense of weight or 
oppression about the heart, with difficult breathing, 
drowsiness, attacks of syncope and cyanotic tend- 
ency on exertion. The pulse varies, at times the 
wall of the artery is rigid, the pulse full, and the 
tension high; at other times the wall is elastic, the 
vessel empty, and the tension low. The respiration 
frequently becomes of the Cheyne-Stokes variety. 
Pulmonary edema may appear as the heart loses 
its strength. The urine becomes scanty, and albu- 
men appears in it. There is edema of the ankles. 
Fatty accumulation with infiltration is one of the 
common causes of death, which is brought about 
by a rupture of the heart or syncope; but more 
frequently there is a gradual impairment of all the 
bodily functions. 

Inspection: — Owing to the excessive amount of 
adipose tissue found in many of these cases, inspec- 
tion does not reveal as much as under a more 
normal condition. Should hypertrophy be combined 
with the fatty condition, there will be a widespread 
precordial heaving and slight pulsation about the 
neck. 

Palpation: — Shows a feeble cardiac impulse un- 
less hypertrophy is present. 

ok .; 



FATTY ACCUMULATION. 99 

Percussion: — May outline a heart normal in 
size, but more frequently the area of cardiac dull- 
ness is increased, due to dilatation or hypertrophy, 
as fatty deposits alone rarely produce a perceptible 
enlargement. 

Auscultation: — The heart sounds are feeble, low 
toned and weak, even when hypertrophy is present; 
this being due to the interference with the heart's 
action and the thickness of the thoracic parietes. 
Naturally the first sound suffers more than the 
second, and murmurs are not uncommon. 

Diagnosis : — This is not easily made owing to 
the difficulty in making a physical examination in 
those suffering from obesity; but weakness of the 
cardiac sounds and impulse, together with general 
obesity should always lead to careful stud)' in this 
particular. 

Prognosis : — If there is evidence of marked myo- 
cardial changes or a history of hereditary tendency 
to obesity, or if the habits are such that the patient 
is unable to control himself, the prognosis should be 
given accordingly. Sudden deaths from rupture of 
the heart, and syncope, in fatty degeneration fre- 
quently occur. 

Treatment: — The treatment resolves itself into 
the reduction of the obesity and the support of the 
heart. The diet must be carefully regulated so that 
with adequate nourishment there is no excess, and 
fats, sugar and starches should be eliminated so far 
as possible. The appetite should not be satisfied at 
any time, and all forms of liquor and tobacco 
should be forbidden. Great care is required in re- 
ducing the obesity, and a most careful examination 

LofC. 



IOO FATTY ACCUMULATION. 

is first necessary, before any form of treatment is 
undertaken. The condition of the heart and arteries 
should be ascertained so far as possible; if the heart 
is sound, the pulse regular, soft, full and the organs 
generally are found to be health) 7 ; active exercise 
such as is found in the modern gymnasium, or walk- 
ing, as recommended as a part of Ertel's method 
should be prescribed. Where the patient is unable 
to follow this method of treatment the Weir Mit- 
chell system is to be preferred, which consists of 
rest and passive exercise in the form of Massage 
and Swedish movement; with a skim milk diet that 
gradually replaces the usual diet until within a 
week's time it takes the place of the regular diet. 
Many of the systems of reduction of obesity are 
dangerous, and while they may reduce the weight, 
I have seen two cases that continued being reduced 
until they died. Frequent bathing with cold or 
tepid water is beneficial. The bowels should be 
kept active. Recently the use of Kissengen and 
Vichy waters in this disease have received some 
attention. A large glass of one of these waters is 
taken after each meal for a week, and is then fol- 
lowed by the other for a week, this alternation is 
continued for several weeks. The acidity of the 
Kissengen may be increased by the use of lemon 
juice, and the alkalinity of the Vichy by the addi- 
tion of the aromatic spirits of ammonia. I have 
followed this form of treatment in one case with 
benefit. Some recommend the sipping of eight 
ounces of hot water a half an hour before each meaL 
Thyroidine, five to eight grains per day, has assisted 
many cases; but fucus vesiculosus in ten to twenty- 
drop doses, three times a day; or sargassum bacci- 



FATTY DEGENERATION. IOI 

ferum, in the same doses, is often of more service. 
Bromide of ammonium has been used in doses 
ranging from five to ten grains three times a day. 
Phytolacca berry juice has the power of dimin- 
ishing the amount of fat in the system. Graphites, 
lycopodium, calcarea carb. and ferr. phos. have con- 
trolled it in typical individuals, assisted by tfie regu- 
lation of their diet and proper exercise. 

The action of the heart should be watched 
carefully and such remedies as sparteine, strychnia, 
digitalis and lycopus will assist in maintaining its 
action when indicated. 

FATTY DEGENERATION. 

This is a condition in which the muscular 
fibres of the heart have been replaced by fatty 
matter. 

Etiology: — Among the remote causes is heredity. 
This is so marked in certain families that sudden 
death is common, and fatty degeneration is the 
most frequent cause. Men, more frequently, are 
victims than women. While cases have been re- 
ported as occurring in children two years old, it 
is seldon met with before middle or advanced life, 
when it is a part of a general senile change. 
Sedentary habits, and the abuse of alcohol are 
fruitful causes; among the more active causes is 
interference with the nutrition of the heart, which 
arises from a modification of the quality of the 
blood; as is met in phthisis, chronic suppuration, 
cancer, anemia, leucocythemia, diabetes, hemophilia, 
gout, and as follows severe hemorrhages. It is met 
as an accompaniment of many of the acute infec- 



102 FATTY DEGENERATION. 

tious diseases as diphtheria, septicemia, typhoid, 
erysipelas, pneumonia and small-pox. It is produced 
by the introduction into the system of certain 
poisons, as alcohol, phosphorus, lead and arsenicum. 
Fatty accumulation with infiltration, hypertrophy 
and gumma produce a fatty degeneration; and a 
diminished activity of the heart will lead to the 
same conditions. 

Pathology : — The appearance in fatty degenera- 
tion depends on whether the disease is general or 
local. The organ is not increased in size unless 
hypertrophy or dilatation is present; and if the de- 
generation is the result of some acute disease the 
heart may be smaller than normal. Owing to pig- 
mentation, the result of destruction of the blood, the 
heart may present a darker color than normal; but 
when degeneration is the result of a pronounced 
anemia, the structure may be pale, having the typi- 
cal "dead leaf" color. When the disease arises as 
the result of a local anemia the change is wholly 
localized. 

The structural changes are so marked that the 
heart muscle may be torn as the result of a forcible 
systole. There is an actual increase of fat in the 
organ and it has a greasy feeling. The left ven- 
tricle is more frequently involved than the right. 
While the auricles are affected, they are much less 
frequently involved than the ventricles. The coron- 
ary arteries are diseased in the great majority of 
cases; arterial sclerosis, calcification or thrombosis 
being present. Other organs are affected in a 
similar manner as the heart, especially the liver 
and kidneys. As a result of the changes in the 
heart, there is weakening of the circulation and 



FATTY DEGENERATION. IO3 

venous congestion takes place in the dependent 
parts. Before any change can be recognized by the 
naked eye, the microscope reveals a number of 
small granules within the muscular fibres, which are 
usually arranged longitudinally; a little later there is 
an increase in the number of granules, a loss of 
striation, a disappearance of the nucler of the 
affected fibres, and at a still later period the gran- 
ules are seen to be large and translucent. Some 
fibres may contain nothing but these globules, but a 
greater number of the fibres are only partially 
affected, and while one fibre may be diseased the 
next may be healthy. Whether all the fat found in 
the tissue is developed within the organ or whether 
a part is from without, is still a debated question, 
with strong evidence in favor of the latter. 

Symptoms : — The number of sudden deaths which 
the post mortem has demonstrated to be due to 
fatty degeneration, places indefiniteness of symptoms 
as the great characteristic of the disease. In many 
cases of cardiac enfeeblement, a careful study of the 
case will lead to this as a probable cause. Pain or 
distress about the heart is not a constant symptom, 
but in one of my cases it was present, extending 
sometimes to one, and occasionally to both shoul- 
ders, and was attended with a feeling of impending 
death. There is breathlessness on slight exertion, 
attacks of syncope, epileptiform seizures, cardiac 
asthma; angina pectoris appears at times and Cheyne- 
Stokes respiration is a late symptom. 

Inspection: — It is frequently impossible to locate 
any apex beat. 

Palpation: — May be no more successful in this 
particular, unless dilatation or hypertrophy be present. 



104 FATTY DEGENERATION. 

The pulse, in cases due to some acute affections, 
may be ioo to the minute, but it is often found 
much slower than normal and may be but 15 to 20. 

Percussion: — The area of cardiac dullness is 
not enlarged unless dilatation or hypertrophy be 
present. 

Auscultation: — May not be able to disclose the 
first sound of the heart at the apex; and if it can 
be recognized, it is faint; but usually it is heard 
better over the lower part of the sternum. When 
an acute febrile disturbance is a cause, a s}'stolic 
murmur may replace the first sound on both sides 
of the heart. Dilatation takes place sooner or later 
and it gives rise to symptoms resembling the fatty 
degeneration itself, as dyspnea, palpitation, a small, 
irregular pulse, and cold, clammy extremities. An 
acute dilatation, dependent on some sudden exertion, 
may occur. In some cases there is a comatose 
condition; in others a condition of insomnia is 
present; and delusions, which ma}/ take on a 
maniacal form, may appear and become permanent. 

Diagnosis: — In such an obscure disease the 
diagnosis should be made with reserve. The ex- 
istence of similar changes in other organs, a fail- 
ing heart in acute diseases, a history of alcoholism, 
a full habit, a cardiac weakness with retarded 
pulse, epileptic attacks, Cheyne-Stokes breathing, 
the arcus senilis, tinnitus aurium and coldness over 
the cardiac region, justifies a probable diagnosis. 

Prognosis : — The prognosis depends on whether 
it arises as a result of an acute or chronic disease. 
In those cases due to acute disease the immediate 
prognosis may be grave, but later favorable. If 



FATTY DEGENERATION. IO5 

due to chronic disease the immediate prognosis may 
be good; but the ultimate prognosis will depend on 
whether the degeneration can be controlled and the 
injuries done compensated for. 

Treatment : — This will vary according as the 
cause of the degeneration is acute or chronic. If 
it is the result of some acute disease; absolute rest, 
appropriate food and diffusible stimulants, with 
such remedies as will maintain the heart's action, 
are indicated. The attendant should bear in mind 
that it is impossible to restore the muscular tissue 
that has been destroyed, and his endeavors should 
be directed to controlling the degeneration and 
maintaining the heart. Inhalation of oxygen is 
most efficient in this class of cases. The habits of 
the patient should be carefully studied, any irregu- 
larity corrected, and alcohol and tobacco stopped. 

Fatty degeneration demands a diet nearly oppo- 
site to that for fatty heart due to obesit}'. The 
diet must be nutritious, and fatty foods, oils and 
starches are not objectionable, as the blood should 
be enriched by all possible methods. The following 
have produced fatty degeneration: Phosphorus, 
arsenic, plumbum, antimony, alcohol, chloroform, 
ether, iodoform, and the following acids: Phos- 
phoric, nitric, sulphuric, oxalic and tartaric. 

Agaricine is of great service in those cases de- 
pendent upon some acute disease where there has 
been profuse sweating; twitching of the muscles is 
a prominent symptom. The heart is weak and 
feeble with violent palpitation at times; the pulse is 
irregular. This remedy is of special service in 
those patients who have been addicted to the ex- 



106 FATTY DEGENERATION. 

cessive use of tea, coffee or tobacco, or who have 
nervous dyspepsia. 

Arsenicum is of service when its great constitu- 
tional symptoms are present; marked chilliness, with 
a desire for warmth; unquenchable thirst for small 
quantities of water at frequent intervals, the pain is 
burning in character, there is anxiety, restlessness 
and an anguish that allows of no rest, with great 
oppression of the chest; violent and unsupportable 
throbbing of the heart, chiefly when lying on the 
back, especially at night. The left side of the heart 
is more frequently affected under this remedy. 

Cuprum met. is indicated when the pulse is 
irregular, intermittent, 'small, very slow and easily 
compressible; there is great muscular debility; the 
beats of the heart are scarcely or not at all percept- 
ible; the sounds are not distinct; there is nausea, 
with pressure on the stomach, anxious oppression of 
the chest, with dyspnea, feeling of anxiety, trembling 
of the hands and feet so he cannot walk and pale 
ness of the face. 

Ferrocyanuret of potassium is indicated in those 
of an enfeebled constitution; the digestive organs 
are weakened; there is sour stomach and flatulence; 
pains are complained of in various parts of the 
body; and insomnia is pronounced. The pulse is 
feeble and easily excited; hands and feet are cold. 
There is palpitation of the heart, tinnitus aurium 
with vertigo, and there is every indication of an 
impoverished condition of the system. 

The apoplectiform seizures have been relieved 
by hydrocyanic acid and gelsemium. 

Hydrocyanic acid will prove of benefit where 



FATTY DEGENERATION. 107 

the heart action is very weak, an irregular pulse, 
hardly to be felt; clammy sweat, dilated pupils, 
breathing slow, deep and gasping. On account of 
weak contractions of the heart there is falling and 
stupefaction. 

Under gelsemium, the heart is slow and feeble, 
the beats cannot be felt, yet the patient desires to 
move, but when he attempts to move, the muscles 
refuse to obey the will and there is a lack of co- 
ordination. 

Iodide of arsenic is called for when there are 
indications of failing heart, especially in those 
advanced in years. The pulse is shotty, there is 
shortness of breath on slight exertion, with pre- 
cordial anxiety and pain; weakness, restlessness, 
and prostration are marked, and arterial sclerosis is 
present. 

Nitrite of amyl or glonoine is frequently of serv- 
ice during the attacks of syncope, as are indicated 
by the symptoms presented. 

Phosphorus has afforded relief in the typical tall, 
narrow-chested, stooping, dark complexioned indi- 
vidual, who is worse from warm foods and drink, 
and from lying on the left side; there is hypochon- 
driacal sadness, great irascibility; fullness, tension 
and lancinating pains in the chest. There are 
fainting fits; venous stasis; and the right side of 
the heart is most involved. 

Plumbum is indicated when cardiac impulse is 
very feeble or not perceptible at all, the heart 
sounds are distinct and there is palpitation with ex- 
cessive dyspnea at times, the pulse is intermitting, 
irregular and of low tension, and at times it may 
be as slow as fifty to the minute, again it will be 



108 FATTY DEGENERATION. 

above one hundred and hardly perceptible. The 
heart is large and flabby; from slight exertion 
there is muscular debility, oppression and fainting 
spells. The patient is melancholy and anxious; 
the bowels are constipated, the stool being in 
form of balls and there is edema of the skin. 

Strychnia stimulates the heart muscle, the 
muscle of respiration; and by regulating their 
action, relieves the dyspnea. It is indicated in 
those nervous irritable individuals, whose nervous 
systems have been undermined by the loss of 
sleep, overwork, etc. Sparteine sulphate is indi- 
cated when compensation is failing and the heart's 
action is weak; the pulse is irregular, feeble and 
dropsy is present; there are dyspeptic symptoms 
with great accumulations of gas in the gastro- 
intestinal canal, and the patient is subject to 
nervous and hysterical attacks. 

Vanadium 6x is of service in strengthening 
the heart's action when there is present fatty 
degeneration of the liver and heart, with degene- 
ration of the arterial walls. It will be found of 
special benefit in those cases where anemia, 
chronic rheumatism, diabetes, neurasthenia, or 
tuberculosis is the exciting cause. It increases 
the appetite and strengthens the digestive function. 

Veratrum viride is of use when there is pro- 
nounced slowness of the heart with a pulse that is 
full and large; when vertigo complicates this slow 
pulse, sanguinaria is to be thought of; if with the 
slowness there is irregular action, then digitalis 
must be studied. 

Zinc phosphide is indicated when muscular 



FATTY DEGENERATION. IOQ 

tremor is a marked symptom and there is present 
debility, paralysis and mental depression. The 
patient is emaciated, cachetic, looks prematurely 
old, has no appetite, and the digestive process is 
painful. 

If the Cheyne-Stokes respiration is a marked 
symptom, atropine should be studied. 

The physician should as far as possible differ- 
entiate fatty accumulation from fatty degeneration, 
in the first a cardiac tonic might at times be per* 
missible, but it is always dangerous in the latter. 



CHAPTER XI. 
SPONTANEOUS RUPTURE OF THE HEART. 

This may be partial or complete. When the 
papillary muscle or the trabecular ventriculi are 
lacerated, the term partial is applied. When the 
whole thickness of the myocardium is involved, it 
is said to be complete. 

Etiology : — Spontaneous rupture never occurs in 
a healthy heart. It is most frequently seen in 
those of advanced years, and in males more fre- 
quently than females. In the majority of cases 
there is present some predisposing cause, as de- 
generation of the coronary arteries, myocarditis, or 
fatty heart. Of the exciting causes, muscular 
efforts have been most frequent, but it has been 
known to occur during sleep. 

Pathology: — The rupture is most frequently 
found in the left ventricle, on the anterior surface, 
near the apex. The direction of the rent varies. 
The pericardial sac is filled with blood, either fluid 
or clotted. The myocardium is paler than in 
health, and under the microscope shows various 
forms of degeneration; atrophic lesion of a granu- 
lar or pigmentary nature; and frequently, an in- 
crease of fibrous tissue. In many cases the coro- 
nary arteries show a degeneration, and valvular 
lesions and endocardial changes are common. 

Symptoms: — In the majority of cases death 
occurs at once, but the patient may survive a 
few hours or days. Five cases have been re- 
ported where the patient lived two days; one case 
where he lived twelve days; one case where he 



SPONTANEOUS RUPTURE OF THE HEART. Ill 

lived one hundred and sixty-eight days; and one 
where pericardial adhesions and fibrinous clot 
brought about a closure of the rent and the 
patient survived fifteen years and then died of a 
second rupture. In those cases where life is pro- 
longed, the symptoms are those of internal hem- 
orrhage with precordial pain, that may be so 
agonizing as to simulate angina pectoris, radiat- 
ing to one or both shoulders and arms. The 
temperature becomes sub-normal; the surface of 
the body is pale, cold, and covered with a cold 
prespiration; the pulse becomes small and frequent, 
and soon cannot be counted at the wrist. Giddi- 
ness, vomiting, syncope and a rapid termination of 
the breathing closes the scene. At times, the 
victim falls; there are a few rapid respirations and 
he is dead. If life is prolonged, a physical exam- 
ination shows symptoms of heart failure and an 
increased area of cardiac dullness. 

Diagnosis :^-Th\s is not always easy. In those 
cases of instantaneous death, it can only be by 
inference; while in those that are prolonged, the 
symptoms of cardiac failure, internal hemorrhage, 
pericardial effusion, and pain points strongly to 
this as the cause. It should be remembered that 
the pulse with angina pectoris is usually resistant 
and regular, while it is feeble in rupture. 

Prognosis: — Usually, death. 

Treatment: — The physician should warn those 
with a degenerated cardiac muscle of the importance 
of keeping quiet and avoiding undue exertion. 
If the rupture has occurred, keep the patient quiet 
and make cold applications to the precordial region 



112 ANEURYSM OF THE HEART. 

and heat to the extremities. Use no cardiac 
tonics. 

ANEURYSM OF THE HEART. 

This is a localized pouch-like dilatation of one 
or more of the divisions of the heart wall. It 
may be acute or chronic. 

Etiology: — It may appear as the result of 
heavy muscular exertion, acute myocarditis, fatty 
degeneration or syphilis. In the chronic forms, 
there is a stretching of a weakened area of the 
cardiac wall that is largely fibroid. 

Pathology: — -They may be single or multiple, 
and vary in size from that of a pea to that of a 
cocoanut. They are seen most frequently near 
the apex on the anterior wall of the left ventricle. 
The heart is usually enlarged; it may be hyper- 
trophied or dilated. Pericarditis is frequent, and 
adhesions often are a result. The tumor usually 
has a constricted neck. Layers of fibrin and blood 
clots are formed in the sac. 

Symptoms : — There are no symptoms that are 
typical of cardiac aneurysm. Palpitation and ir- 
regularity are among the early symptoms, while 
pain and dyspnea appear later. While a murmur 
may be present, there is nothing about it that is 
characteristic. The apex beat may be diffused and 
weak. If the aneurysm is large, the area of 
cardiac dullness is increased. After a prolonged 
disturbance of the heart's action the development 
of chronic pericarditis is very suggestive of 
aneurysm. 

Diagnosis: — It is impossible during life to posi- 
tively diagnose these cases. \ 



NEW FORMATIONS. 113 



Prognosis : — From post-mortem, we know that 
about one-fourth of the recorded cases gave no 
symptoms of existence during life and were first 
revealed by the autopsy. Where it is possible to 
make even a probable diagnosis, the prognosis is 
not good. 

Treatment: — This is dependent upon the diag- 
nosis being correct. Cardiac tonics should be 
avoided, rest in bed is advisable and the resistant 
muscular exercise adopted. 

NEW FORMATIONS. 

All forms of malignant growth are met with in 
connection with the heart. They are most fre- 
quently secondary. While found at any age they 
usually appear about the middle period of life, 
more males than females being afflicted. Of the 
benign growths, fibromata, lymphomata, myomata, 
lipoma and cardiac cysts have been demonstrated. 
These may be latent or they may give rise to 
cardiac disturbances, as precordial pain, breathless- 
ness, an irregular, weak cardiac impulse and weak 
heart sounds. When there is a tendency to heart 
failure without valvular lesions, rheumatism, alco- 
holism, there is known to be a cancer else- 
where, or a marked cancerous cachexia is present, 
it should always lead one to think of a possible 
involvement of the heart. The prognosis in the 
cancer of the heart is grave and the treatment is 
symptomatic. 

TUBERCULOSIS OF THE HEART. 

The myocardium does not suffer from tubercu- 
losis to the extent that the serous membranes of 



114 CARDIAC EMACIATION OR ATROPHY. 

the heart do. It may result from a chronic tuber- 
culosis of adjacent organs, but more frequently it 
is found in connection with acute miliary tubercu- 
losis. It appears as gray tubercle and large 
caseating masses of myocardium. Under whatever 
form it may appear; the symptoms are so obscure 
that a positive diagnosis is difficult during life, 
and a post mortem has been the confirming test. 
At times, tuberculosis of the valves has been 
noted in connection with pulmonary and medias- 
tinal tuberculosis. 

CARDIAC EMACIATION OR ATROPHY. 

This is diminution in the size and weight of 
the heart due to a lessened amount of muscular 
tissue. 

Etiology : — This may involve the whole or a 
part of the heart. Some hearts are small in 
proportion to the body; this may be congenital or 
the result of arrested development. Old age pro- 
duces the senile heart, which is small. A frequent 
cause is some of the wasting diseases, as tuber- 
culosis, cancer, diabetes, etc. A loss of blood, 
degeneration of the coronary arteries, pericardial 
adhesions and fatty heart have also been respon- 
sible for cases. 

Pathology : — Diminution in size and a loss of 
weight are the two principle changes — with these 
there is a loss of fat from about the organ. The 
color is paler than in health and the surface has 
a wrinkled or puckered appearance, is dense and 
hard to the touch. Under the microscope the 
muscular fibres are smaller than in health, the 



SYPHILIS OF THE HEART. II5 

muscular cells diminished in size, have lost their 
cylindrical appearance and become fusiform. 

Symptoms : — The prominent symptoms are often 
those that accompany the condition that induces 
atrophy, as breathlessness, palpitation on exertion, 
and edema of the dependent parts. 

On physical examination, the arteries are empty 
and the tension of the pulse is low. In making 
the examination the condition of the lungs should 
be ascertained; as any retraction of the lungs 
makes the heart appear larger than natural, and 
any distention (as emphysema) makes it appear 
smaller. The cardiac impulse is usually weak. 
The apex beat may appear to be strong owing to 
exposed condition. If the heart is close to the 
chest wall the cardiac sounds may appear abnorm- 
ally clear, otherwise they are weak. 

Diagnosis : — This is often problematic. But an 
actual diminution in the area of cardiac dullness, 
with a feeble and low tensioned pulse, breathless- 
ness, weakness, and the presence of some disease 
that is capable of producing such a condition is 
evidence enough to pronounce it a case of atrophy 
of the heart. 

The prognosis depends on the primary disease. 

Treatment : — This must be directed to the man- 
agement of the constitutional symptoms. Absolute 
rest with the employment of those means that will 
control waste and strengthen the heart is indicated. 

SYPHILIS OF THE HEART. 

Etiology: — This may be the result of heredity 
or infection. 



Il6 SYPHILIS OF THE HEART. 

Pathology : — The muscular walls are the usual 
seat of the trouble; but the valves, especially their 
bases may be involved alone. The changes may 
consist of either fibroid formations or true syphi- 
litic gummata. 

Symptoms: — During the treatment of every 
case of syphilis a careful examination of the heart 
should be made from time to time, in order that 
no structural change appears and gains a hold 
unperceived, and that the condition of the heart 
may be known if possible, before syphilitic changes 
take place. The symptoms vary according as the 
myocardium or valves are the seat of the origi- 
nal disease. If they are confined to the myo- 
cardium they appear slowly. There being a grad- 
ual loss of cardiac strength, and pericarditis or 
endocarditis appears as the surface of the myocar- 
dium is approached by the new formations. This 
class of cases terminate suddenly; in those cases 
where the valves are the seat of the original 
disease, the symptoms appear slowly and are 
usually first noticed when the secondary conditions 
present themselves; as hypertrophy or dilatation. 
Acute aortitis is common where the endocarditis 
involves the aortic valves. Fibroid degeneration, 
aneurysm, dilatation and valvular lesions are the 
principal sequelae. 

Diagnosis: — This must be based upon the his- 
tory of the case, upon the presence of similar 
lesions in other organs, and the relief obtained 
from treatment. 

Prognosis : — Syphilis of the heart is nearly al- 
ways found in cases that have been neglected, and 
proper treatment should prevent it in acquired 



SYPHILIS OF THE HEART. 117 

cases. When the heart is once involved, the prog- 
nosis depends on whether or no the structural 
changes have advanced to such a stage that they 
have become fibrinous; if they have, aneurysms are 
liable to develop, independent of the integrity of 
the surrounding tissue. When the valvular changes 
are most pronounced the compensation will not be 
perfect, as the myocardium has suffered to a cer- 
tain extent. If the disease is arrested by the 
treatment, such growths as have not already be- 
come fibrinous may be absorbed. Death may 
result from syphilitic marasmus, or from rupture 
of the heart. 

Treatment: — This implies the careful manage- 
ment of every case of syphilitic infection, and a con- 
stant observation for from three to five years after 
its last exhibition, that it may be known to be 
eradicated from the system. When it is recog- 
nized as involving the heart, the patient should 
be put to bed and all muscular effort forbidden 
until the actual cardiac strength is determined; 
and the muscular strength regained if it is lost. 
The diet should be such as will assist in restoring 
the heart muscle, a nitrogenized diet being the 
best. When the patient is confined to the bed 
inhalations of oxygen is often of service. If the 
heart needs assistance in overcoming the valvular 
defects, nitroglycerine, strophanthus and digitalis 
are of service, but should be used very carefully; 
especially if the myocardium is involved. Pneumo- 
therapy may be of service in assisting compensa- 
tion and equalizing the circulation. 



Il8 WOUNDS OF THE HEART. 

WOUNDS OF THE HEART. 

These occur more frequently in the right than 
left ventricle, and in the right than left auricle. 
The injury has been of different kinds and the 
opening of various forms and sizes. 

Symptoms : — These vary with the extent of the 
injury; when the wound is large there is collapse, 
syncope and death. Should the injury be one 
where the wound is small, or involves in any 
way the coronary arteries, there is a gradual pale- 
ness with weakness of the pulse and a weakened 
cardiac sound and impulse, with a degree of faint- 
ness and possible vomiting on nervous disturbances. 
At times, the opposite symptoms may present 
themselves in the form of a frequent and forcible 
pulse and cardiac excitement. 

Physical Signs: — These may not reveal any- 
thing that is definite; in some cases there may be 
an increase in the area of cardiac dullness, and a 
murmur may be produced by the escaping blood, 
that is hissing in character. 

Adjacent organs often suffer laceration as well 
as the heart. 

Diagnosis: — It is not always easy to decide 
whether the heart is implicated or not. External 
hemorrhage, unless severe, is not diagnostic. A 
knowledge of the instrument causing the wound, 
and the depth it penetrates, often assists. It is 
not advisable to probe the wound for diagnostic 
purposes, as it may displace a clot. The profuse- 
ness of the hemorrhage is to be taken into con- 
sideration, more than its persistence. 

Prognosis: — It should be remembered that ap- 



AMYLOID DISEASE. II9 



parently serious lesions have been recovered from, 
while the more trivial have proven fatal. Most 
frequently the gravity of a case depends upon the 
first shock and the degree of the hemorrhage; a 
mild degree of pericarditis is not unfavorable, but 
an endocarditis is always unfavorable. 

Treatment: — The first question is whether the 
case is such as to demand surgical interference; 
in such cases there is cardiac compression; re- 
moval of foreign bodies, the removal of portions 
of fractured ribs, or septic material, and the sew- 
ing and drainage of the pericardium. The indica- 
tion in this class of cases is to control the hemor- 
rhage, relieve the shock and maintain the heart. 
Cardiac stimulants should not be used. The 
patient should be kept quiet and the pain relieved. 
Unless there are marked indications, clots should 
not be removed; and cold applications may be 
used if symptoms of secondary inflammation arise, 
and the case treated symptomatically. 

Ligatures have been inserted, to close the 
wound, with success. 

AMYLOID DISEASE. 

This is the result of chronic malaria, syphilis, 
lead poisoning or the continued suppuration of a 
bone. The amyloid material is found deposited in 
the interstitial tissue of the myocardium and along 
the line of the blood-vessels. Similar changes are 
to be found in other organs as the spleen, liver 
and kidneys; and its presence in these organs 
must be relied on in making a diagnosis. 

CALCAREOUS DEGENERATION. 

Calcareous infiltration of the myocardium has 
been noticed occasionally during post mortem. 



CHAPTER XII. 

ENDOCARDITIS, 

Endocarditis is an inflammation of the endo- 
cardium or lining membrane of the heart. 

When confined to the valves it is termed 
valvular endocarditis. When limited to the mem- 
brane lining cavities it is called parietal. Clini- 
cally it presents an acute and chronic form. The 
former may be simple or malignant, the latter is 
fibrotic. 

The right side of the heart is most frequently 
involved during fetal life and in many cases of 
the malignant form, apart from this the left side 
is most frequently involved. 

SIMPLE ACUTE OR VERRUCOSE ENDOCARDITIS. 

Etiology: — Acute articular rheumatism is the 
most frequent cause, 70 per cent, of the cases 
having been attributed to it. In the severe types 
of rheumatic fever both the endocardium and 
pericardium are involved, while in the milder 
form but one membrane may be affected. It is 
during the second week of rheumatic fever that 
the endocardium shows involvement generally, but 
in some cases the endocarditis is the first symp- 
tom of a rheumatic attack. Chorea and acute 
tonsillitis in those of rheumatic tendencies are fre- 
quently associated with endocarditis, as well as 
many of the acute infectious diseases; as scarlet 
fever, measles, influenza, the confluent form of 
small pox, pneumonia, diphtheria and gonorrhea. 
In those cases of acute Bright's disease where the 






SIMPLE ACUTE OR VERRUCOSE ENDOCARDITIS. 121 

pericardium is involved, endocarditis is nearly al- 
ways present. As many of the diseases with 
which endocarditis is associated are diseases of 
childhood, it is not surprising that it should be 
frequently seen early in life. 

Pathology : — The changes are confined for the 
most part to the valves; but occasionally is found 
upon the walls. When on the valves, it is on the 
side exposed to the blood current, where there is 
the greatest friction when the valves close. Early 
in the process there is a proliferation of the con- 
nective tissue corpuscles, which results in numer- 
ous small round cells; these at first are in masses, 
but gradually spread out, into the areolar tissue 
next to the myocardium. The endothelial cover- 
ing of the affected parts gives way, the round 
cell infiltration projects into the blood current, 
and a deposit of a fibrin takes place on the 
exposed surface. These fibrinous vegetations or 
cauliflower excrescences may be as large as a pea, 
and interfere with the blood current. They may 
become fibrinous and a chronic fibrinous change 
result, they may undergo a necrotic degeneration, 
or an ulcerative process may separate them and 
the emboli cause infraction in different organs. 

Symptoms: — Cases occur in which there are no 
symptoms indicating the involvement of the endo- 
cardium, in nephritis there may be a rise in the 
temperature of one or two degrees. The patient 
complains of dyspnea, and palpitation may be 
discernible by palpation, and he inclines to the 
left side. The pulse may not be increased in 
rapidity. If there is much involvemet of the myo- 
cardium, distress in the precordia and dyspnea is 



122 SIMPLE ACUTE OR VERRUCOSE ENDOCARDITIS. 

more pronounced. Inspection and palpation during 
the early stages may show an increase in the force 
and area of the apex beat. While percussion gives 
negative results, auscultation may not reveal any 
murmur during the first week. The first derange- 
ment noted by auscultation is a prolongation of the 
first sound of the heart, which is gradually replaced 
by a murmur and other evidence of disturbance of 
the circulation, as indicated by palpitation and 
irregular heart action. It should be remembered 
that murmurs occur from other causes than diseases 
of the valves, and that endocarditis may exist with- 
out a murmur. 

Diagnosis : — In many cases this is difficult, again 
it may be difficult to say whether the case is simple 
or malignant. The history of the case and general 
symptoms should be studied carefully. 

Prognosis : — Complete recovery is not the rule. 
The greater percentage of these cases terminate in 
chronic fibrotic changes, other cases may become 
malignant. When death results from embolism this 
is indicated by the enlarged spleen. 

Treatment : — Patients subject to rheumatic at- 
tacks should wear flannel next the skin constantly; 
with the appearance of an attack they should go to 
bed, the extremities be kept warm and thus relieve 
the peripheral circulation. The diet should be 
restricted to milk. If milk is objected to, it may 
be combined with vichy or seltzer water. The 
room should be well ventilated and the temperature 
kept between 70 and 75 ° F. It is doubtful if any 
local application is of service. When the patient is 
placed in bed he should be between flannels. The 
fluids taken should be restricted so far as possible. 



SIMPLE ACUTE OR VERRUCOSE ENDOCARDITIS. 1 23 

When there is much nervous excitement a warm 
bath, 90 to 95 F., repeated two or three times 
during the twenty-four hours has a soothing effect. 
In treating those conditions that give rise to endo- 
carditis every care should be taken to avoid its 
appearance as a complication. When pain becomes 
a marked symptom, hot applications are beneficiaL 
During the very early stages cold applications may 
be of service. 

Veratum viride: — This remedy is frequently the 
first demanded by the case when the heart's action 
is violent. There is congestion of the lungs. The 
patient is full blooded and plethoric; the pains are 
violent; the fever is high; the tongue is white or 
yellow, with a red streak down the center. 

Aconite: — Is indicated by the general febrile 
condition. The temperature is high: the pains are 
acute and there is the anxiety, restlessness and fear 
of death that characterizes this remedy. 

Spigelia :— There is a sensation of great pressure 
in the chest, with violent palpitation and cutting 
pains in the heart, that extend down the left arm. 
There is violent palpitation of the heart, so that it 
can be heard and seen through the clothing. 

Cimicifuga: — This remedy should always be 
studied when endocarditis appears during chorea or 
rheumatism, in which the bellies of the muscles are 
most involved. Besides the violent aching pains in 
the parts affected, there is a severe headache either 
confined to the forehead or top of the head, when 
it appears as if the top of the head would fly off. 
There is also pain under the left nipple and down 
the left arm. 



124 SIMPLE ACUTE OR VERRUCOSE ENDOCARDITIS. 

Convallaria: — Will be found of service, not dur- 
ing the very acute attacks, but when the tempera- 
ture is nearer normal, the heart action is still 
forcible, there is great nervousness and dyspnea. 

Digitalis: — This remedy should be studied care- 
fully before it is given in endocarditis; but when 
there is vomiting, vertigo with delirium, increasing 
dyspnea, spasmodic cough, expectoration with mixed 
blood, livid turbid face, and the patient cannot lie 
down or be moved without dyspnea. 

Cactus grand: — There are sharp pains with op- 
pression of the breathing; great palpitation, pulse is 
quick, tense, and there is a sense of constriction 
about the heart. 

Arsenicum: — When, late in the course of the dis- 
ease, the pulse becomes weak, soft and irregular; 
there is dyspnea with restlessness and anxiety. 
There is more or less edema of the cellular tissue, 
and hyperemia of the liver. 

Bryonia alb.: — When there is a high fever with 
an intense frontal or occipital headache, the least 
motion aggravating the condition, this remedy 
should be studied. 

Belladonna: — Will be found of service, especially 
in children when there is throbbing of the cerebral 
arteries, violent action of the heart, a hard pulse, 
intense headache with delirium or stupor, aching in 
the cardiac region, with injection of the conjunctiva 
and dilated pupils. 



CHAPTER XIII. 
MALIGNANT ENDOCARDITIS. 

Synonyms : — Ulcerative, infective, diphtheritic. 

Definition: — This is a destructive inflammation 
of the endocardium, the result of microorganisms 
that occurs in connection with blood poisoning, the 
symptoms being those of the latter. 

Etiology : — It may result from any disease where 
sepsis is possible, as septicemia, pyemia, puerperal 
fever, pneumonia, erysipelas and any ulcerative pro- 
cess. A depraved condition of the system or a 
lowered vitality favors its development. 

Pathology : — The most marked changes are con- 
fined to the valves and chorda tendinea and are in 
the form of vegetations, ulceration and suppuration. 
The development of the vegetations is much the 
same as found in. simple endocarditis. They vary 
in size, some being as large as a pea and of a 
greenish yellow color. On account of the infection 
present, they are soon cut down by a necrotic pro- 
cess which may involve the endocardium; or by a 
process of ulceration; assisted by the blood current, 
the vegetations are loosened and the emboli carried 
to some organ where an infection takes place; this 
is most frequently in the spleen, after this the 
kidneys and meninges. The former seat of the 
vegetations now becomes an ulcer which may be 
superficial or deep. At times, abscesses form in 
the valves, and rupturing, leave a weakened point 
that may give rise to dilatation or perforation; 
with so much septic material in the blood it is not 



126 MALIGNANT ENDOCARDITIS. 

surprising that a septic or typhoid condition de- 
velops. 

Symptoms: — At times the symptoms of the car- 
diac involvement are over-shadowed by those of the 
preceding disease. Frequently the first thing noted 
is a marked chill which is followed by a fever that 
is remittent, intermittent or typhoidal in type; pros- 
tration is pronounced; the pulse is rapid and the 
perspiration is profuse. 

Physical examination shows an enlarged spleen; 
the other organs show infection. 

In the typhoid form the symptoms are not as 
pronounced as in the septic form. The disease 
takes a more chronic course. At first there may 
be only an intermittent pyrexia but sooner or later 
the patient becomes apathetic, the tongue is brown, 
sordes appear on the teeth; there is a low mutter- 
ing of delirium, with subsultus tendinum and a 
profuse perspiration. The temperature is high, but 
irregular, and chills may appear from time to time. 
The patient gradually drifts into unconsciousness 
and coma. The cardiac signs are often wanting, 
but petechia and embolic infarction assist the diag- 
nosis. 

The septic form is met with most frequently in 
connection with puerperal sepsis, or some suppura- 
tive process. But the chill, fever, profuse perspira- 
tion found in pyemic conditions, with delirium, 
metastatic abscesses, rapid pulse and respiration 
with jaundiced condition, leave no doubt that a 
pyemic condition is present; but the absence of any 
endocardial symptoms may lead one to believe that 
no such condition exists, until a post mortem re- 
veals it. 

Diagnosis: — This is difficult, as it is liable to 



MALIGNANT ENDOCARDITIS. 127 

be mistaken for typhoid fever, and at times acute 
simple endocarditis. It should be remembered that 
in typhoid fever there is neither rigor nor evidence 
of embolism; the previous history of the case and 
Widal's reaction should distinguish it. It may be 
differentiated from simple endocarditis by the lack 
of the pyemic condition in the latter. 

Prognosis: — It is fatal in all well authenticated 
cases. 

Treatment: — The treatment is not satisfactory 
as the disease is fatal. The patient should be kept 
quiet, to give the heart all possible rest. The chest 
should be protected with flannel or cotton-wool. 
The diet should be nutritious but simple and easily 
digested. The quantity of fluids taken should be as 
low as possible. Baths are frequently of great ser- 
vice. They should be warm, 90 F., and repeated 
during the twenty-four hours. Hot applications 
over the precordia often bring relief. 

If the result of streptococcus, the anti-streptococ- 
cus serum might be tried. 

Arsenicum alb.: — This remedy meets the toxic 
condition that is present in many of these cases. 
The pulse is feeble and irregular, it may be slow 
or fast. There is great anguish and restlessness 
with a cachetic appearance; the skin is cold and 
pale. There is great thirst and a sensation of in- 
ward heat. 

Lachesis: — This remedy should be thought of 
when there is rapid decomposition of the blood with 
hemorrhages from the mucus membranes, the in- 
flammation being of the most malignant character. 
All the symptoms are worse after sleep. The face 
presents an expression of great suffering. The 



128 MALIGNANT ENDOCARDITIS. 

tongue is dry, black, stiff and cracked, and trembles 
when the patient protrudes it. 

Crotalus horridus: — This remedy is adapated to 
all fevers that assume the low typhoid type, with 
great prostration, languor, and frequent fainting 
spells. Hemorrhages appear from all of the orifices 
of the body; even from the pores of the skin. It 
produces great trembling of the whole body. ' The 
symptoms are most pronounced on the right side of 
the body and has more influence on fat people than 
those that are lean. 

Phosphorus : — The patient upon whom this 
remedy acts most favorably is tall, slender, with a 
fair skin, sanguine temperament, sensitive disposi- 
tion and of quick and lively perceptions. It should 
be studied in fever, where the injury to the vital 
force is pronounced the result of absorption of 
poisonous matter, from the products of malignant 
disease. One cardinal indication that is often com- 
plained of, is a sensation of great weakness and 
emptiness in the abdomen. 

Echinacea angustifolia: — From the proving and 
clinical observations comes the evidence that we 
have here a great remedy in septic conditions. It 
has produced loss of appetite with weakness in the 
stomach and formation of large quantities of gas 
that passes both up and down; there is pain in the 
right hypochondriac region, with loose, yellow and 
very offensive stools, that are followed by great 
exhaustion. The face becomes pale, the pulse slow 
and great weakness is complained of. 

Salicylic acid ix: — In dealing with septic condi- 
tions, this remedy should be studied, as it controls 
many of these conditions. 



CHAPTER XIV. 
CHRONIC OR FIBROID ENDOCARDITIS. 

This may appear as the result of an acute in- 
flammation or it may be chronic from the begin- 
ning. 

Etiology: — Of the causes of chronic endocarditis 
some are operative during embryonic life. In cer- 
tain families there is a tendency to fibrotic degener- 
ation, while in others it has been ascribed to gout, 
syphilis and alcoholism. It has been estimated that 
fifty per cent, of the cases of chronic endocarditis 
is caused by rheumatism. While measles, chorea 
and pneumonia are each the cause of some cases. 
Occupations that demand long continued, heavy 
muscular exertion develop endocarditis and a de- 
generation of the myocardium, when coupled with 
high arterial tension. This degeneration is one of 
the results of old age; and is noticed in certain 
families as a hereditary tendency, which is probably 
due to certain toxic chemical substances circulating 
in the blood. Traumatism has been followed by 
endocarditis at times. It has been observed that in 
early life it is the mitral valve that is most fre- 
quently diseased, while later it is the aortic. The 
mitral is the one most frequently diseased in women, 
the aortic in men. 

Pathology : — The fibrotic changes may be con- 
fined to the valves or to the endocardium lining 
the cavities of the heart. It may involve the whole 
valve or any portion of it. Among the cavities, 
the endocardium lining the npex of the left ventri- 
cle is most often infected. The changes met with 



I30 CHRONIC OR FIBROID ENDOCARDITIS. 

consist of an infiltration of the sub-endothelial con- 
nective tissue with round cells, which develop into 
a fibrillated structure, and as a result there is pro- 
duced a fibroid thickening of the endocardium which 
may be uniform or nodular. This fibroid tissue 
contracts, giving rise to deformity and agglutination 
of the cusps. These changes are first noticed in 
the corpora arantii. When the aortic valve is in- 
volved there is the formation of a dense fibrous 
ring at the base of the cusps; when the mitral 
valve is involved there is thickening, contraction 
and adhesions of the cusps, with a contraction of 
the chordae tendinse; which draws the cusps back 
toward the papillary muscle and does not allow a 
closure of the auriculo-ventricular orifice. On account 
of the thickening and contraction of the cusps, an 
insufficiency is brought about. This thickening and 
adhesions of the edges may increase until the 
whole appearance of the valve is changed and there 
results a small slit in a fibrous diaphragm, which is 
known as the buttonhole slit. At times, on account 
of the contraction of the fibrinous ring at the back 
of the cusps and the rigidity of the valve, stenosis 
takes place to such an extent that the mitral orifice 
is like an inverted cone. Frequently, incompetency 
and stenosis is associated at the same orifice. 
When the fibrotic change has taken place its ten- 
dency is to undergo necrotic and calcareous degen- 
eration. Lime salt is deposited until the whole 
valve becomes a calcareous mass. At times ulcer- 
ation is associated with these calcareous changes 
and when once started, has a tendency to progress. 
These changes may be arrested at any stage and 
the process be renewed again. 



CHRONIC OR FIBROID ENDOCARDITIS. 131 

Symptoms: — Chronic endocarditis, in itself, pro- 
duces no characteristic symptoms. It is only when 
its secondary effects are observed in derangement 
of the circulation that they produce the character- 
istic features. Pyrexia will only be present when 
there is an acute attack of the chronic affection. 
There is no change in the temperature, and so long 
as the compensation is full, there is nothing in the 
pulse or respiration to indicate its presence. The 
local symptoms and physical signs of chronic endo- 
carditis are connected with the valvular lesion, and 
the circulatory disturbances that they produce are 
considered under the various valvular lesions. 

Diagnosis: — The diagnosis of chronic endo- 
carditis is that of the valvular lesion which it pro- 
duces. 

Prognosis: — No just opinion can be expressed 
with regard to any of these lesions without a 
knowledge of the effects of the particular lesion 
upon the myocardium, and this requires close ob- 
servation of the case for some time. A single 
lesion is always more favorable than a mixed one. 
And much depends upon the cause, the factors that 
are now operative, and those that are liable to fol- 
low. The family history is always to be taken into 
consideration, whether they are long or short lived, 
and whether they were subject to valvular disease. 
Age should be considered, as at the extremes of 
life valvular changes are dangerous, and often cause 
death about the period of puberty. The habits of 
the patient must always be considered as well as 
the occupation and surroundings. It must be ascer- 
tained if the patient is addicted to the use of 
alcohol or if there is a uric acid diathesis, a renal 



132 CHRONIC OR FIBROID ENDOCARDITIS. 

or specific affection present. The nature of the 
lesion should also be considered, its extent, mode of 
origin, length of duration and the gravity of the 
particular lesion; as aortic incompetence is worse 
than mitral incompetence and a mitral obstruction 
worse than an aortic obstruction. Of their mode of 
origin, those from a sclerotic process are less 
serious than those from rheumatism, as the latter 
are always subject to acute attacks. The effect of 
the lesion upon the heart itself and the other organs 
and functions, must also be taken into consideration. 

Treatment : — Valvular lesions in themselves do 
not demand treatment, it is only when they are 
attended with other lesions or disturbances that it 
is necessary. Prophylaxis, while of service in cer- 
tain forms of heart disease, is not applicable here, 
as many of the cases do not consult a physician 
until well established. Age and sex must always be 
taken into consideration in the treatment, as they 
form limitations to the treatment. In those cases 
where compensation is full, while medicine may be 
of no service, yet there is a task in watching that 
no unnecessary strain be produced. The residence 
should be, as far as possible, in a climate that is 
favorable and where the extremes of temperature 
are not marked. The diet should be regulated 
that it may not contain an excess of nitrogenous 
food, while the quantity of alcohol and other stimu- 
lants should be carefully regulated, if allowed at all. 
The occupation should be such that sufficient exer- 
cise in the open air can be obtained to keep up a 
healthy condition of the system. In all cases the 
amount of rest and exercise should be regulated, 



CHRONIC OR FIBROID ENDOCARDITIS. 1 33 

that all the functions of the body may be kept in 
a healthy condition. 

In advising with reference to the life of a young 
subject with valvular disease, it is not advisable to 
withdraw them altogether from the activity of the 
world, but rather to have a life of fairly good ex- 
ercise, and one where the mental strain is not too 
pronounced. An intelligent patient may do much 
to avert trouble, if the nature of the lesion is ex- 
plained, that he may know his limitations. The 
patient, while the lesion is compensated for, should 
be careful about moving to high altitudes. A great 
deal may be accomplished by attention to the diet 
of cardiac patients. The meals should be taken 
regularly; rive to six hours apart and no food be- 
tween, unless marked cardiac failure is present, when 
the food should be in a concentrated form and 
taken every three hours. 

Digitalis purp: — When this remedy is indicated 
there is great anxiety, oppression, dyspnea, with 
fainting and sinking at the stomach. There is 
extreme prostration and exhaustion. The patient 
falls as if he were dying, and has a sensation that 
the heart would stop beating if he moved. The 
pulse is feeble, irregular, fluttering and intermittent; 
or it may be very slow, when any motion as rising 
from a chair or bed will cause it to become rapid, 
weak and jerky; The face may be pale and death- 
like, or there may be a blueness of the skin, lips 
and tongue. Respiration is difficult, sighing and 
irregular. There is coldness of the extremities, 
with a cold clammy perspiration. 

When for any reason, another remedy must be 
chosen similar in its action to digitalis, the follow- 



134 CHRONIC OR FIBROID ENDOCARDITIS. 

ing should be studied: Strophanthus, convallaria, 
adonis-vernalis, oleander and euonymus. 

Cactus grand.: — This remedy has a profound 
action upon the heart and may be demanded in any 
form of cardiac distress. " When it is indicated," 
the patient believes his disease incurable; there is 
fear of death, and he complains of a great pressing 
in the head as if a great weight lay on the vertex, 
which is better from pressure. There is a sensation 
of constriction in the heart as if an iron band pre- 
vented its normal movement. Palpitation of the 
heart continues day and night, is worse while walk- 
ing, during the night and from lying on the left side. 
There are pains at the apex of the heart which 
shoot down the left arm to the finger tips. The 
pulse may be irregular, at times it is fast, again 
slow. 

Naja tripudians: — This remedy will be found of 
service after acute inflammations, where it will 
clear up many valvular affections. Both the physi- 
cal and the mental powers are depressed. There 
are severe stitching pains in the region of the 
heart, with fluttering and palpitation of the heart. 
The pulse is slow, irregular and weak. An irritat- 
ing cough with tightness, fullness in the region of 
the larynx with hemoptysis is noticed in many of 
these cases. The naja patient is melancholy, and 
broods over imaginary difficulties, has a dull frontal 
headache and severe throbbing and aching in 
temples. All symptoms are worse from the use 
of stimulants, and are better from walking or riding 
in the open air. 

Convallaria majalis: — This remedy will be found 



CHRONIC OR FIBROID ENDOCARDITIS. 1 35 

of most service when the right side of the heart is 
suffering from disease of the lungs, as emphysema, 
and in cases where a respiratory stimulant is de- 
manded. The heart's action is weak, exercise caus- 
ing a fluttering sensation which will continue but a 
short time, when the heart will appear to stop 
beating and then start suddenly, causing a faint 
feeling. The pulse is intermittent, but full and 
compressible. At times there is great pain in the 
uterine region. It will be found to relieve the dysp- 
nea accompanying emphysema and fibroid phthisis, 
and should be studied in orthopnea, the result of 
disease of the mitral valve. The dyspnea is aggra- 
vated by moving, there is faintness with palpitation 
of the heart and the desire to take a deep breath. 
When this remedy is indicated the tincture, one 
or two drops every three hours, has given good 
results. 

Lycopus Virginicus: — This remedy is indicated 
in different pathological conditions of the heart, in 
endocarditis following rheumatism; it is frequently 
of service when there is constricted pain and tender- 
ness about the heart, of a rheumatic nature. The 
heart sounds may be indistinct, or the cardiac action 
so tumultuous and forcible that it can be heard at 
a distance. The pulse varies; at times it is quiet, 
intermittent and feeble. There is often a cough 
with pulmonary irritation and hemoptysis with pain 
in the chest and cardiac weakness. 

Strophanthus hisp. : — This remedy is indicated 
when the heart's action is weak and rapid from 
muscular weakness and there is the irregular rhythm 
that is characteristic of mitral stenosis; when 
dyspnea is present especially of the nervous type. 



I36 CHRONIC OR FIBROID ENDOCARDITIS. 

In the heart failure of the aged, and in heart dis- 
ease of children it is often of great service. 

Kalmia latifolia: — This remedy produces pain 
that simulates rheumatism, which is worse in the 
muscular system* The pains and rheumatism ex- 
tend from the centre to the periphery and shift 
suddenly. There is rheumatism with oppressed 
breathing, with stitching pains in the lower part of 
the chest and through it, above the heart to the 
shoulder blades, with pain in the left arm. There 
is palpitation of the heart, with hypertrophy, valvu- 
lar insufficiency, anxiety and oppressed breathing. 
The pulse is weak and quick, or slow and feeble. 
There is pain and pressure in the arm. 

Ferrum: — This remedy is frequently indicated 
in this class of cases, in persons of sanguine tem- 
perament, who are pettish and quarrelsome, easily 
excited, and the least contradiction angers them. 
The face, lips and mucous membrane is pale but 
becomes red and flushed on the least pain, exertion 
or motion. They are subject to headache which 
continues for several days, it is hammering, beating 
or pulsating in character, causing the patient to lie 
down; during this time there is an aversion to 
eating or drinking. The digestive organs suffer and 
there may be great hunger or loss of appetite, with 
extreme dislike for food; at times there is vomit- 
ing of everything as soon as taken, or a diarrhea 
of an undigested stool present. The patient is re- 
lieved by walking slowly, but the great weakness 
causes him to lie down soon; congestion of the 
lungs with hemoptysis is often present, with palpi- 
tation of the heart, and anemic and organic cardiac 
murmurs may be present. 






CHRONIC OR FIBROID ENDOCARDITIS. 1 37 

Arsenicum alb.: — When this remedy is indicated 
there is great emaciation with restlessness, anxiety 
and a loss of strength so that the patient can hardly 
walk, especially after great exertion as mountain 
climbing. There is violent palpitation of the heart, 
especially at night, which is visible and audible. 
The pulse is quick, weak and irregular. 

Arsenicum iod.: — This remedy will be found of 
great service when there is, in connection with the 
symptoms just mentioned under Ars. alb., marked 
fibroid degeneration of the heart and arteries. 

Aurum mur. : — This remedy produces an in- 
creased activity of the heart's action. The lungs 
are hyperemic. The least exertion produces a sen- 
sation of a crushing weight under the sternum. 
There is congestion of the blood in the other 
organs; and frequently a history of acquired syph- 
ilis; and melancholy is present. The heart and 
arteries often show degeneration. There is sensi- 
tiveness to cold, and yet the patient desires to go 
into the cold air as it brings relief. 

Rhus tox. : — When this remedy is indicated 
there is usually a history of rheumatism, the symp- 
toms being relieved by motion. There may be a 
slight aggravation on first moving, but continuous 
motion brings relief. The patient is worse from 
damp air, from getting wet, and relieved by 
warmth. There is anguish and anxious sadness, 
worse at night; the sleep is disturbed by anxious 
dreams. There are shooting, lancinating pains in 
the chest, worse while sitting, but seldom while 
exercising. There is a sensation of weakness and 
trembling referred to the heart. While sitting 
quietly there is violent palpitation, with shooting 



138 CHRONIC OR FIBROID ENDOCARDITIS. 

pains in the region of the heart and with a painful 
sensation of paralysis and numbness in the left arm. 

Nux vomica: — This remedy is to be studied 
when the patient is irritable and sensitive to every- 
thing. There is chilliness, with a sour smelling 
breath, constipation and an early morning awaken- 
ing, (3 a. m.) and falling asleep just when he should 
get up. There are shooting pains in the region of 
the heart; with palpitation which is worse after 
dinner and while lying down; with heaviness of the 
chest and an inclination to vomit. There are also 
symptoms of asthma and constriction with oppres- 
sion in the chest, which is worse during the night 
and when going up an ascent. 

Aconite: — This remedy is not called for in this 
connection frequently, but at times it will be, where 
there is great restlessness, with anxiety and fear of 
death. There are stitch-like pains with hacking 
cough and hemoptysis. The patient is aroused from 
sleep, being in great distress. The face is red and 
a physical examination reveals a congestion of the 
lungs. 

Adonis vernalis: — This remedy will be found of 
service when dilatation of the heart is taking place, 
as indicated by the diminished heart's action and 
the lowering of the blood pressure generally; as a 
result, the function of the kidney is lessened and 
marked dropsy appears. 

Baryta carb.: — This remedy should be studied 
carefully, as clinically it has produced marked action 
upon the circulatory system. There are indications 
of degenerative changes in the arteries, especially 
in the aged and those who are childish, have a 
a weak memory and an imbecile condition. 



CHRONIC OR FIBROID ENDOCARDITIS. 1 39 

Belladonna : — While acting upon others, this 
remedy affects most favorably those of a plethoric 
constitution, who have blue eyes, light hair, fine 
complexion and a face that is apt to be red and 
bloated. There is violent beating of the heart that 
can be felt in the head and chest; respirations are 
short, anxious and rapid. 

Sulphur: — The sulphur patient is of a scrofulous 
diathesis; nervous temperament; quick in motion 
and temper;" is sensitive to atmospheric changes, is 
subject to venous congestions. His complaints, 
whatever they may be, are continually relapsing and 
the carefully selected remedy fails to produce the 
desired effect. There are shooting pains in the 
region of the heart with palpitation, which may be 
visible; it is attended with anxiety and aggravated 
by going up an ascent. There is a sensation of 
pressure in the cardiac region, as though the heart 
had not room. The symptoms are all aggravated 
at to to 12 a. m., when there is a sensation of 
sinking. Water and warmth also aggravates. 
There is a tendency to religious and philosophical 
reveries, and often a history of suppressed eruptions 
and discharges. 

Stigmata maidis: — In cases where the dropsy 
has become severe, this remedy will be found most 
serviceable. It renders the heart's action slower 
and stronger, it becomes of a better rythm, the 
arterial tension is increased, and the venous tension 
reduced. Other remedies that may be of service 
in dropsy are, apocynum cann., eupatorium purp., 
iberis amara., copaiba and arsenicum. 

Lithium carbonicum: — This remedy has been of 

service to those whose hearts are suffering from the 
10 



I4O CHRONIC OR FIBROID ENDOCARDITIS. 

effects of rheumatism or gout. The symptoms 
that have guided its selection have been, the great 
soreness and tenderness about the heart; which at 
times, is attended with shocks and jerks of the 
heart. There is a general soreness and distress, 
with pressure in the region of the heart, that is 
relieved by urinating. The urine is scanty and 
dark, with uric acid deposits. A headache is com- 
plained of, which is relieved while eating. 

Spongia tosta: — This remedy is frequently use- 
ful in organic diseases of the heart, when the 
patient is unable to lie with the head low; if he 
does, it brings on an attack of dyspnea and suffo- 
cation. There is violent palpitation of the heart 
with pain. Frequently the patient is aroused from 
sleep as if smothering, sits up in bed with flushed 
face and rapid, hard breathing. 

Kali muriaticum: — This remedy should be studied 
in the exudating stage of inflammation. When it 
is indicated there is a white or gray coating at 
the base of the tongue. There is a sense of con- 
striction of the chest with palpitation; there is per- 
ceptible, but not accelerated beating of the heart. 
The pulse may be accelerated or quiet and slug- 
gish. 

Ferrum phos. : — This remedy is to be thought 
of in the first stage of any inflammatory process, 
before the exudation has taken place. The pulse 
is soft, full and quick. There is thirst, fever and 
sweat which does not relieve the pain. The 
patient is anemic, and all the pains are aggravated 
by motion and relieved by cold. 

Calcarea carbonica: — This remedy corresponds 
to many forms of rheumatism and is frequently of 



CHRONIC OR FIBROID ENDOCARDITIS. I4I 

service when the heart is involved. The patient 
lives in dread of heart disease and consumption; 
is ill-humored and obstinate. There is a tendency 
to obesity or emaciation, with chilliness in the 
open air. There is coldness of the extremities 
which are covered with a clammy perspiration, 
also cold sweats about the head and chest. There 
is hunger soon after eating, with acidity and heart- 
burn. In the female the menses are too early and 
too profuse. There is shortness of breath on 
ascending, with wheezing respiration, anxious op- 
pression and palpitation of the heart. This remedy 
is frequently of service in bringing the whole 
system up to a healthier state and in this way 
assists in maintaining a compensation. 

Cimifuga racemosa: — This remedy will assist in 
removing from the system the rheumatic poison 
and thus enable the heart to regain its equilib- 
rium. There is excessive muscular soreness, with 
pains in the neck, with restlessness, twitching, 
trembling and mental gloom. Severe pain is pres- 
ent in the left chest below the fifth or sixth ribs. 
The pain extends from the region of the heart, 
all over the chest and down the left arm, which 
feels numb as if bound to the side. There is pal- 
pitation of the heart with cerebral congestion, a 
livid face, dyspnea, cold perspiration on the head, 
and numbness of the body. The heart's action 
ceases suddenly with a sensation of impending 
suffocation. 

Natrum mur. : — This remedy has frequently 
been of service in the management of valvular 
disease. The patient is sad and melancholy with 
an inclination to weep, and is aggravated by con- 



I42 CHRONIC OR FIBROID ENDOCARDITIS. 

solation. The symptoms are all worse from lying 
down, especially at night. The sleep is disturbed 
by dreams. There is a violent palpitation of the 
heart that is attended with anxiety, is worse from 
every movement of the body and while lying on 
the left side. The palpitation is irregular, inter- 
mittent and jerking in character, and is accom- 
panied with jerking pains in the region of the 
heart. 

In cases where the compensation is rapidly 
failing the following remedies will be found the 
best to check the process: Digitalis, strophanthus, 
caffeine and strychnine. 

The caffeine may be given hypodermically; a 
solution, prepared of one drachm caffeine and one 
drachm of salicylate of sodium, to two drachms of 
distilled water, of which 10 or 15 drops are in- 
jected as required. 

Strychnia will be found of great service at a 
later period than digitalis, when doses from one- 
hundredth to one-twentieth of a grain will be ser- 
viceable. 



CHAPTER XV. 
AORTIC INCOMPETENCY. 

Definition: — The aortic valves close imperfectly, 
allowing a portion of the blood to pass back into 
the ventricle during its diastole. It is most fre- 
quently associated with aortic disturbance. 

Etiology: — This lesion is most frequently met 
with in strong, vigorous individuals during the 
active period of life, whose work calls for pro- 
longed physical endurance; this with alcoholism 
and syphilis forms a trio which gives rise to an 
induration, thickening and contraction of the cusps, 
known as fibrotic endocarditis; which is the most 
frequent cause of aortic incompetency. Acute 
rheumatic endocarditis is not as frequent a cause 
here as at the mitral orifice; but when at this valve, 
it is usually of the ulcerative variety and is rapidly 
fatal. Locomotor ataxia and endarteritis obliterans 
are occasional causes. Extremes of temperature 
and all those conditions that have a tendency to 
develop fatty degeneration, sclerosis, or a gouty 
diathesis have their influence. This is the orifice 
that suffers most frequently from traumatism; .the 
left posterior cusp being the one most often rup- 
tured during the heart's diastole. Among the 
occasional causes are congenital malformation, 
vegetations obstructing the closure of the orifice, 
atheroma of the aorta and aneurysmal dilatation 
of the commencement of the aorta. 

Pathology : — The changes are found either in 
the cusps or in a dilatation of the aortic orifice; 
when in the cusps, it is due to a shortening, 



144 AORTIC INCOMPETENCY. 

thickening and puckering; the result of chronic 
endocarditis or fibrotic changes that have extended 
from the aorta. Adhesion of the valves to the 
walls of the aorta takes place; also rupture of the 
valve. In acute endocarditis, vegetations may 
appear on the cusps, which frequently terminate 
in ulceration and loss of substance; at times, 
it produces fusion of the cusps and narrowing of 
the orifice. With these changes, patches of sclero- 
sis, atheroma and calcification of the aorta are 
often present. 

The coronary arteries are ultimately involved 
in the fibrotic change, which by constricting their 
orifice, limits the blood supply to the cardiac 
walls and affects its nutrition. In a normal condi- 
tion, the recoil of the aorta by pressing the blood 
against the perfectly closed aortic valve, becomes 
the main force in filling the coronary arteries; but, 
in incompetency of this valve, the aorta is unable 
to perform this part of its function, and as a 
result the arteries are not filled, and there exists a 
second cause leading to degeneration of the 
myocardium. 

The effects of incompetency are felt first by the 
left ventricle, surcharging it with blood, and giving 
it an increase of work; as a result it becomes 
hypertrophied, and the cavity dilated. So long as 
the coronary arteries are in a healthy condition 
and the blood of such a character as to maintain 
the necessary metabolism of the myocardium, the 
hypertrophy is such as compensates and maintains 
an equilibrium; but should the heart outgrow the 
possibilities of the coronary arteries, degenerative 
changes take place, which lead to dilatation and 



AORTIC INCOMPETENCY. I45 

cardiac failure. In some cases, owing to the great 
stress, the mitral valve becomes incompetent, allow- 
ing regurgitation of the blood into the left auricle, 
the pulmonary veins and lung tissue; giving rise 
to a passive hyperemia that ultimately affects the 
right side of the heart. The great variation in 
the arterial blood pressure leads to far reaching 
effects in the nutritive processes. 

Symptoms: — So long as compensation is per- 
fect there may be nothing to warn the victim of 
danger. But the rupture of the valve due to 
strain or traumatism may give rise to severe pain 
and dyspnea, with disturbance of the circulation. 

Cardiac pain is one of the most common 
symptoms of this disease; it varies from an un- 
easiness to the most profound a^ony. Headache 
and throbbing about the head are often present 
on exertion. Subjective symptoms of the eyes are 
complained of. Pallor of the surface is often 
noticed. The capillary pulse is observed as well 
as the excessive pulsation of all the arteries. 
There is present what is known as the " water 
hammer," or Corrigan's pulse. It is abrupt, large, 
of short duration and falling away from the finger 
the instant it reaches it. Sphygmographic tracing 
brings out some of the points distinctly. The 
ascent of the curve is abrupt, steep and high; the 
descent almost as swift; there may be considerable 
tidal wave but the dicrotic notch and wave are 
slightly marked. Occasionally, a venous pulse of 
the peripheral veins is developed. It appears as 
a wave passing from the periphery towards the 
centre, following the ventricular systole, and when 



I46 AORTIC INCOMPETENCY. 

present, is seen best in the veins of the back of 
the hand. 

Inspection: — This may reveal but little that is 
abnormal, but more frequently, the face is pale; 
the area of the apex beat is enlarged extending to 
the mid axillary line, at times its force is increased. 
The carotid pulsation can be seen to the angle of 
the jaw. 

Palpation: — Shows an increased force to both 
the cardiac systole and diastolic recoil; also the 
definite location of the apex beat. When the hand 
is placed over the aortic area a diastolic thrill may 
be felt; but a systolic thrill is usually felt over 
the carotids and subclavian arteries. 

Percussion: — The area of cardiac dullness is 
increased both in the vertical and horizontal direc- 
tion. The left border shows a greater extension 
to the left and downward than does the right side 
in the opposite direction. 

Auscultation: — Reveals the characteristic dias- 
tolic murmur, with or obscuring the second sound, 
the character of which varies from the soft blow- 
ing to the harsh, rasping quality; and at times, it 
produces a musical sound. The location of the 
maximum intensity of this murmur varies, but it 
is most frequent at the right of the sternum, or 
at the level of the second costal cartilage; but 
may be to the left of the sternum or even at the 
apex. It is conveyed downward toward the apex. 

Diagnosis: — This is based on the peculiar 
character of the radial pulse, capillary pulsation, 
the condition of the arteries in general, the left 
ventricle and the diastolic murmur heard to the 
right of the sternum. 



AORTIC INCOMPETENCY. I47 

Prognosis : — This is the cardiac disease in which 
the life of the patient hangs on a thread. The 
cause and nature of the disease; whether other 
valves are involved or not; the condition of the 
arterial walls; the kidneys and general condition 
of nutrition must be taken into account. The 
cases that result from endocarditis are more favor- 
able than those from degeneration with anginal 
seizures; as the coronary arteries are frequently 
involved in the latter. If the hypertrophy com- 
pensates fully for the lesion; if the second sound 
is distinct in the cervical arteries and the arterial 
tension good, the indications are hopeful. If the 
cardiac contractions are enfeebled, the sounds 
weakened, the arterial tension lowered, the indi- 
cations are unfavorable. 

Treatment: — So long as compensation is per- 
fect, no treatment, apart from the general rules 
to be observed in all lesions where hypertrophy 
is marked, is demanded. All fatigue whether 
muscular or mental is to be avoided. The diet 
should be carefully regulated, all alcohol and 
tobacco stopped, and a high physiological condition 
maintained. The patient should receive a most 
careful examination from all standpoints and be 
treated accordingly. As compensation begins to 
fail, absolute rest in bed for three or four weeks 
is often of service. When this is not practical, 
all the emotions should be under control and a 
quiet life in the country is to be chosen. Strain- 
ing, of all forms, should be avoided, and especially 
that demanding the use of the hands above the 
head. The nutrition should be as high as possi- 
ble, that the heart muscle may not suffer. Nitrog- 



I48 AORTIC INCOMPETENCY. 

enous food is to be preferred to sugar, sweets, 
vegetable and animal fat. The patient should 
sleep with as little under the head as possible, and 
thus relieve both the cardiac circulation and the 
tendency to pulmonary congestion. The bowels 
should move at least once a day. The body 
should be warmly clad, and exposure to cold 
should be avoided. Warm baths often benefit 
these cases. 

For the indications of the following remedies 
and others that may be called for, the reader is 
referred to the Therapeutics of Chronic Endocar- 
ditis: Iodide of arsenic, aurum, cactus, convallaria, 
baryta carb., belladonna, aconite. 



CHAPTER XVI. 

AORTIC STENOSIS. 

Definition : — This is a defect of the aortic valve 
that interferes with the passage of the blood from 
the left ventricle into the aorta. 

Etiology: — Aortic stenosis is most frequently 
found in middle and advanced life, but may occur 
at any age; more men are affected than women. 
It is noted among those whose avocation calls for 
prolonged physical labor. Acute, sub-acute and 
chronic endocarditis are all responsible for some 
cases, but the latter is the most frequent cause. 

Pathology : — The point of obstruction varies, it 
may be at the origin of the arterial channel, or 
any part of the arterial aspect of the cusps; or it 
may result from vegetations, some of which are 
small while others are large, and undergo a cal- 
careous degeneration. At times there is a thick- 
ening and retraction, with degeneration and calci- 
fication of the cusps; occasionally, they become 
attached to each other and give rise to a con- 
tracted funnel-shaped aperture, the apex of which 
projects into the aorta. The wall of the left ven- 
tricle becomes hypertrophied; dilatation follows and 
in time, incompetency of the mitral valve, which 
causes a hypertrophy and dilatation of the left 
auricle; while later a passive hyperemia of the lungs 
and changes in the right side of the heart result. 
The aorta is frequently diseased, there being sclero- 
tic changes and dilatation, which give rise to irreg- 
ular bulging on the concave side of the vessel. If 
sclerotic changes are present in the aorta, one or 



I50 AORTIC STENOSIS. 



both of the coronary arteries are apt to be in- 
volved, leading to their occlusion and degeneration 
of the myocardium. 

Symptoms: — So long as compensation is suffi- 
cient no subjective symptoms are complained of. 
Pain is often present and presents many of the 
symptoms of angina pectoris. Dyspnea with pal- 
pitation is often present. The aspect of the 
patient is but little changed, apart from a tend- 
ency to pallor which may be slight. The com- 
plexion may be modified by general conditions 
that accompany the aortic lesion. 

There are two conditions giving rise to these 
symptoms; in one, the orifice is narrowed; in the 
other, the orifice is normal but there is a dilata- 
tion of the aorta, just beyond the orifice, that 
produces symptoms in many particulars similar. 

Inspection: — This may show a bulging of the 
precordia if there was an enlargement of the 
heart during childhood; sometimes a distinct pul- 
sation in the third, fourth and fifth intercostal 
spaces on the left side. The apex beat is dis- 
placed downward to the left. The arteries show 
but little if any pulsation. 

Palpation: — The pulse is regular, tardy and 
sustained. The apex beat is found to be down- 
ward, and to the left; it is usually strong, sus- 
tained and at times accompanied by a systolic 
thrill; which as a rule, is confined to the aortic 
area and adjacent parts, but may be conducted 
over the whole chest. 

Percussion: — Shows the area of cardiac dull- 
ness to be increased downward and to the left. 



AORTIC STENOSIS. 151 



Auscultation: — Reveals a systolic murmur syn- 
chronous with the apex beat; although its duration 
may vary, it usually continues well into the second 
sound. The character of the murmur may be soft 
and blowing, or harsh and rasping, again it may 
be musical. The point of maximum intensity of 
the murmur is usually about the middle or upper 
part of the manubrium, but may vary. The mur- 
mur is propagated to the' summit of the sternum 
and outward along the clavicle, as well as down 
the sternum. It may be heard in the carotids, in 
the subclavians, down the arms and even in the 
femoral arteries. In a fair proportion of cases the 
murmur is heard to the left of the sternum, when 
all the symptoms connected with the case must be 
taken into consideration; to differentiate it from 
murmurs due to pulmonary stenosis. Contrary to 
what might be expected, the aortic second sound 
is usually increased in loudness. The first mitral 
sound is increased in intensity and the tone low- 
ered. When dilatation of the ventricle has 
occurred, it may be replaced by a murmur. 

Diagnosis: — The most positive sign is the sys- 
tolic murmur carried into the vessel of the neck 
and extremities. The pulse varies to such an 
extent that it cannot be relied upon. There may 
be absence of a thrill from the base of the heart, 
and hypertrophy may be marked. 

It must be differentiated from a mediastinal 
tumor pressing upon the aorta; an aneurysmal 
dilatation of the ascending aorta; and a patent 
ductus arteriosus. Tumors within the mediastinum 
that cause stenosis of the aorta, are usually from 
the thymus gland, mediastinal connective tissue, 



152 AORTIC STENOSIS. 



parietal pericardium, or periosteum of the thoracic 
walls. At times these growths, while pressing 
upon the aorta, give rise to symptoms simulating 
aneurysm. In other cases the pressure produces a 
systolic murmur heard over the manubrium, which 
is conveyed along the arteries; there is present an 
area of dullness on percussion, which is sufficient 
to differentiate it from disease of the aortic valve. 
In this class of cases no changes are found in the 
arterial system in general and no accentuation of 
the second aortic sound. 

The only form of aneurysmal dilatation that 
might be mistaken for an aortic obstruction is the 
fusiform variety. But in this the area of dullness 
extends farther to the right at the second and 
third costal cartilage. Auscultation gives two 
signs of simple aortic dilatation; first a soft, blow- 
ing systolic murmur, produced by eddies, which 
take their origin within the dilated aorta; the 
murmer being carried along the vessels of the 
neck; the second symptom is an accentuation of 
the second aortic sound. It should be remembered 
that arterial sclerosis, especially when accompanied 
with cirrhotic changes in the kidney, produces 
this same symptom. 

Pulmonary obstruction may be mistaken for 
aortic obstruction, especially when the murmur of 
the latter is heard to the left of the sternum, but 
in pulmonary obstruction the murmur is never 
conveyed to the arteries of the neck. A patent 
ductus arteriosus is congenital, it is characterized 
by a loud systolic murmur, which may be carried 
beyond the second sound, its greatest intensity is 
in the second left intercostal space, about one inch 



AORTIC STENOSIS. 1 53 



and a half from the middle of the sternum. The 
murmur may be propagated through the whole 
body, but never to the vessels of the neck and 
arms. 

Prognosis: — This is more favorable in aortic 
obstruction than in any other organic valvular 
lesion; not having the tendency to sudden death 
by aortic incompetence. It may, however, inter- 
fere with the coronary arteries. 

Treatment : — Should the origin of this lesion be 
a sclerotic process, a careful regulation of habits, 
food, drink, rest and exercise is demanded. The 
food should be highly nitrogenous and plenty of 
fluid taken. Exercise should be well regulated, 
but any physical or mental stress removed. 

When cardiac failure ensues, as it will sooner 
or later, the treatment must be conducted on gen- 
eral principles. 

For the indications of the following remedies 
and others that may be called for, the reader is 
referred to the Therapeutics of Chronic Endocardi- 
tis: Arsenicum, cactus, nux vom. , phosphorus, 
antimonium tart. 

AORTIC STENOSIS AND REGURGITATION. 

A combination of these lesions are more fre- 
quently met with than one alone; many cases that 
pass for aortic incompetence, upon a more careful 
examination, are found to be a combination of 
these two. 

Etiology: — The causes producing these lesions 
are the same as those producing the single lesion; 
the same remark holds true of the morbid ana- 
tomy. There is, in all cases, a thickening and 



154 AORTIC STENOSIS. 



roughness of the cusps, together with a deformity 
and retraction that prevents their proper closure. 

Symptoms: — These are the combined effects of 
the two lesions, with the symptoms of the most 
marked in the ascendency. The apex .beat is dis- 
placed downward and outward, and a thrill both 
systolic and diastolic may be present. The area of 
cardiac dullness is increased and both systolic and 
diastolic murmurs heard. 

Prognosis : — The combination while more serious 
than a stenosis, is not much more serious than an 
incompetence alone. 

The treatment is that of aortic incompetence. 



CHAPTER XVII. 
MITRAL INCOMPETENCY. 

Definition: — This is an imperfect closure of the 
mitral valve that allows the blood to regurgitate 
into the left auricle. 

Etiology : — Of the causes of mitral incompetency, 
acute rheumatic endocarditis is the most fruitful. 
Febrile states, wasting diseases, anemia and diseases 
that produce a degeneration of the myocardium 
have been causes at times. A simple dilatation of 
the auriculo-ventricular ring, or disease of the 
chordae tendinese, allowing the cusps to pass back- 
ward into the auricles; are responsible for the in- 
competency in some cases. 

Pathology : — In many of these cases, obstruction 
is associated with the incompetency. When endo- 
carditis is the cause, the cusps are rigid, contracted, 
and there is often fusion of their margins, and veg- 
etations. At times the auriculo-ventricular ring is 
dilated, due to relaxation of the muscular structure 
surrounding the orifice. Of the changes in the walls 
of the heart, the left auricle will be found dilated 
and hypertrophied, the latter being the more marked 
if the regurgitation is not pronounced. The ven- 
tricle also shows dilatation and hypertrophy. 

Symptoms:— So long as the compensation is full, 
there may be no symptom. But as soon as the 
compensation begins to fail, there is a sensation of 
uneasiness or weight about the precordia. Breath- 
lessness appears and a cough that is attended by 
a watery sputum. This, above all others, is the 
heart lesion that gives rise to headache, illusions, 



156 MITRAL INCOMPETENCY. 

delusion and hallucination, with a sensation of faint- 
ness and giddiness. A slight degree of jaundice is 
common, the eyes are congested, the lips and nos- 
trils are cyanotic and there is a dusky flush on the 
cheeks. The pulse has a reduced pressure. 

Inspection: — The apex beat is usually down- 
ward and outward. The impulse at times is dif- 
fused. 

Palpation: — A simple, mitral incompetence is 
never accompanied by a thrill. The apex is dis- 
placed to the left. When hypertrophy predomi- 
nates, the apex beat is downward and to the left. 
When dilatation predominates, it is outward and 
up, and is more diffused. 

Percussion: — No other valvular lesion produces 
such an increase in cardiac dullness as this one. 
It is increased laterally and downward. 

Auscultation : — Reveals a systolic murmur which 
accompanies or replaces the first sound, having its 
point of maximum intensity at the apex. It is pro- 
jected in all directions, but especially toward the 
axilla and scapula. The character of the murmur 
varies, usually it is soft and blowing but it may be 
harsh and rasping. At times it is heard as dis- 
tinctly at a point between the left scapula and 
vertebral column, as it is at the apex of the heart. 
The second pulmonic sound may be accentuated or 
doubled. 

Diagnosis: — This is usually easy, but it is not 
easy to say whether it is due to a valvular lesion 
or muscular incompetence. The broad area of car- 
diac dullness; the systolic murmur, heard best at 
the apex, and conveyed, to the left axilla, also to 



MITRAL INCOMPETENCY. 1 57 

the back at times; with an accentuation of the 
second pulmonic sound are characteristic. 

Prognosis: — If the incompetence is of slight 
degree it may exist for years without any interfer- 
ence with the health. If the general health is good 
and no pulmonary symptoms appear, the absence 
of venous stasis, the freedom of the right side of 
the heart from implications and an energetic cardiac 
impulse, are all favorable conditions. When it 
appears early in life, it interferes with the process 
of development and leads to disturbance of the gen- 
eral nutrition. 

Treatment : — This varies according to the stage 
at which the case comes under observation. If 
compensation be perfect, there is but little to be 
done apart from a careful attention to the nutrition, 
that full compensation be maintained. When com- 
pensation is failing, absolute rest is to be insisted 
upon, and the general treatment should be based 
upon the effects that the lesion has upon the right 
side of the heart and lungs. 

The circulation of the blood through the lungs 
should be favored as far as possible, that the blood 
may be aerated. 

For the indications of the following remedies and 
others that may be called for, the reader is referred 
to the Therapeutics of Chronic Endocarditis: 
Digitalis, naja, lycopus, Crataegus, kalmia, cactus, 
strophanthus, adonis vernalis. 



CHAPTER XVIII. 
MITRAL STENOSIS. 

Definition: — This is a narrowing of the mitral 
valve, that interferes with the current of blood pass- 
ing from the left auricle to the left ventricle. 

Etiology : — This is an affection of early life that 
is seen more frequently in women than men. It is, 
at times, congenital. Endocarditis, — the result of 
rheumatism, chorea and chlorosis, is the most fre- 
quent cause. 

Pathology : — The changes are located either on 
the cusps or at the auriculo- ventricular ring; when 
at the latter, they consist of either vegetations or a 
sclerotic process, or a combination of these two. 
In the greater proportion of cases, the changes are 
confined to the cusps and chordae tendineae. There 
may be adhesions of the edges of the cusps, giving 
rise to constriction of the orifice; or on account of 
the involving of the chordae tendineae the cusps do 
not act properly. At times, vegetations are found 
upon the auricular side of the valve; again, the 
changes are purely sclerotic. On account of its 
extra work the left auricle becomes hypertrophied, 
but as cardiac failure takes place, dilatation re- 
sults. The left ventricle is hypertrophied as a 
result of the extra diastolic aspiration demanded, 
and there is a general venous stasis. In due time 
the right ventricle shows the effect of the deranged 
circulation, by becoming hypertrophied and later 
dilated. The lungs give evidence of venous stasis. 
As the compensation fails, edema and hydrothorax 
appear. 



MITRAL STENOSIS. 



J 59 



Symptoms: — While compensation is full there is 
usually no symptom to indicate the presence of this 
lesion, apart from a dyspnea which appears under 
muscular effort. A little later the blood gives evi- 
dence of not being aerated, a broncho pneumonia 
may develop, or a cough with expectoration of a 
fluid sputum that may contain blood, and pulmon- 
ary hemorrhage may take place. Pain at the apex 
and over the anterior chest wall, while not con- 
stant, appears in some cases and may extend to the 
left shoulder and arm. As the failure of compensa- 
tion becomes more marked, the dyspnea becomes 
more constant, the congestion and edema of the 
lungs, with blood-stained and serous expectoration 
more pronounced; and recurrent febrile attacks, due 
to endocarditis, are to be expected. And while 
ascites and congestion is the rule, general anasarca 
is rare. 

Inspection: — The apex beat may be seen to the 
left and downward, but usually it is nearly normal. 
The increased tension in the pulmonary artery may 
give a pulsation in the second left intercostal space, 
and epigastric pulsation may be noted. 

Palpation: — At first the pulse is regular, but 
later it becomes irregular in force and rythm. The 
hand over the precordial region reveals a thrill at 
the apex, which is presystolic or diastolic in rythm. 

Percussion: — The line of dullness is extended 
outward, along the third and fourth left intercostal 
space. If the right auricle is enlarged there is dull- 
ness extending to the right. 

Auscultation: — This gives the pathognomic sign 
of mitral stenosis, a presystolic murmur heard best 



l6o MITRAL OBSTRUCTION AND REGURGITATION. 

just above and one inch within the apex beat. It 
is rough and vibratory. It is heard up to the first 
sound, which is sharp and short. The pulmonic 
sound is accentuated, and the second sound at the 
base of the heart may be doubled. 

Diagnosis: — This is based on the presystolic 
thrill and murmur heard near the apex; the char- 
acter of the pulmonic second sound and the in- 
creased size of the heart. 

Prognosis: — This is second to aortic regurgita- 
tion only, in point of gravity. By care the patient 
may live for some time. But there must be no 
fatigue, physical or psychical, that would produce a 
break-down. 

Treatment : — The first object should be to ob- 
viate the tendency to pulmonary disturbance, as the 
pulmonary veins are the first to suffer. To accom- 
plish this, the clothing and general care should be 
such as will protect the patient from sudden changes 
of the temperature. If pulmonary complications ap- 
pear, it is advisable to confine the patient to a well 
ventilated apartment where there is an equal tem- 
perature, and if thought best, steam may be em- 
ployed. 

For the indications of the following remedies 
and others that may be called for, the reader is 
referred to the Therapeutics of Chronic Endo- 
carditis: Convallaria, lycopus, naja. 

MITRAL OBSTRUCTION AND REGURGITATION. 

A combination of these two lesions is more fre- 
quently met with than either of the lesions alone. 

Etiology and Pathology : — These lesions are 
always due to organic disease, either in the form of 



MITRAL OBSTRUCTION AND REGURGITATION. l6l 

endocardiac changes or degenerative processes. Of 
the two, the former is more frequently met with; 
but in the aged, the latter is frequently met with 
as the cause. The changes present in this condition 
are, the development of vegetations upon the cusps 
which interfere with the blood current and a proper 
closure of the valves, so that both obstruction and 
incompetence are present. In other cases there is 
thickening and roughening of the valves, while the 
tendinous cords are more resistant than in health, 
and as a result, there is the combined lesion. In 
another class of cases, there is fusion of the cusps 
to such an extent that a mere slit of small dimen- 
sions results. The effects of the combined lesions 
are greater than of either alone. The auricle is 
greatly dilatated and hypertrophied in some cases. 
The pulmonary circulation, the right side of the 
heart and systemic veins suffer as a result. 

Symptoms: — While the symptoms are those of 
combined lesions, they are more pronounced than 
of either lesion alone. For the symptoms presented 
by the separate lesions, the reader is referred to 
the article treating of it. With a greater disturb- 
ance, the symptoms of both the pulmonary and 
systemic circulation are more pronounced, as well 
as the pulmonary hyperemia, edema of the de- 
pendent parts and catarrhal conditions of the 
mucous membranes. The pulse becomes irregular 
at an earlier date. Pulsation of the cervical veins, 
and epigastric pulsation are frequently observed. 

Percussion: — Outlines an enlarged heart; and 
auscultation gives the combined murmurs. The 
systolic mitral murmur may be all that is detected. 
The first sound may be roughed in character and 



l62 MITRAL! OBSTRUCTION AND REGURGITATION. 

may sound like the "b" of the word •" rub." The 
second pulmonic sound is accentuated to a more 
marked degree than when but one of the lesions is 
present. 

Diagnosis: — The irregularity of the heart's pul- 
sations, with the roughened first sound passing into 
a systolic murmur and followed by an accentuation 
of the pulmonic second sound, are considered char- 
acteristic of the double lesion. 

Prognosis: — With the combined lesions the 
prognosis is worse than for either lesion alone. 
While not attended with the pain that is character- 
istic of aortic disease, yet this lesion gives rise to 
a continued distress. 

Treatment: — This is practically that of the 
the single lesions, but must be carried out faithfully. 



CHAPTER XIX. 
PULMONARY INCOMPETENCE. 

Definition: — This is a defect of the pulmonary 
valve which allows the blood to regurgitate into the 
right ventricle during its diastole. 

Etiology: — It is an affection of early life and is 
rare. It is frequently congenital; in which case, it 
is associated with pulmonary stenosis. Of those 
cases that are developed during life, rheumatism and 
the eruptive fevers are the most frequent causes. 
Degenerative changes, as sclerosis and atheroma, 
due to alcoholism have been noted as causes later 
in life. 

Pathology : — Those cases that develop during 
life are the results of endocarditis or degenera- 
tion. The cusps are shrunken, thickened, indurated 
and distorted. At times they are ulcerated and 
may be perforated. The effects on the heart are, 
hypertrophy and dilatation of the right ventricle, 
and at times, of the auricle. It should be remem- 
bered that a functional incompetence is present at 
this orifice at times. 

Symptoms: — Dyspnea and cyanosis are noticed 
on exertion and do not cause any annoyance during 
repose; as cardiac failure appears, these s}'mptoms 
become continuous and are then attended with a 
cough and lung difficulties. On account of the 
dilatation of the right ventricle and regurgitation of 
the tricuspid orifice, venous stasis, with enlargement 
of the abdominal organs follow; with catarrh of 
the mucous surfaces and effusion into the serous 



164 PULMONARY INCOMPETENCE. 

sacs. Clubbing of the fingers and arching of the 
nails are frequently seen. 

Inspection: — Shows the apex beat displaced to 
the left, a distinct pulsation in the epigastrium and 
a distended condition of the veins of the neck which 
have a pulsation at times. 

Palpation: — Confirms inspection, and may reveal 
a thrill heard over the base of the heart, with its 
greatest intensity to the left of the sternum, syn- 
chronous with the second sound. 

Percussion: — Shows the area of cardiac dullness 
extended both to the right and left. 

Auscultation: — A diastolic murmur is heard re- 
placing the second pulmonic sound, which has its 
greatest intensity at the second left intercostal space. 
It may be rasping or soft and blowing in character, 
and increased during expiration, it is not transmitted 
to the cervical vessels. 

Diagnosis: — It must be remembered that the 
murmur of aortic incompetence may also be heard 
to the left of the sternum. But a diastolic pulmo- 
nary murmur is not conveyed to the carotids, as 
is a similar murmur of the aortic orifice; neither is 
it attended with Corrigan's pulse, capillary pulsa- 
tion, nor heard distinctly at the apex; while cyano- 
sis, dyspnea and clubbing of the fingers are char- 
acteristic of pulmonary incompetency. A patent 
ductus arteriosus presents the dyspnea and cyanosis, 
but in this, the murmur and thrill are of late sys- 
tolic rythm. 

Prognosis: — This is grave. Bronchitis and 
broncho- pneumonia are common in adults, and 
whooping cough in children, are always rendered 



PULMONARY STENOSIS. 1 65 

more serious by its presence. Pulmonary tubercu- 
losis is also a frequent complication. 

Treatment: — Embraces those prophylaxis that 
prevent bronchial affections, which are such fatal 
complications. Attention should be given the pro- 
tection of the body, the air breathed, ventilation 
and the general treatment for cardiac failure. 

See Therapeutics of Chronic Endocarditis. 

PULMONARY STENOSIS. 

Definition: — This is a diseased condition of the 
pulmonary valve that interferes with the systolic 
current of blood from the right ventricle. 

Etiology: — It is the most frequent of all the 
congenital heart lesions, and the most rare of those 
developed during extra uterine life. Of those cases 
that develop after birth, endocarditis from rheuma- 
tism, the eruptive fevers and specific infection are 
the most frequent causes. It is frequently found 
associated with the disease of the left side of the 
heart. 

Pathology : — This may be confined to the cusps, 
which are thickened, indurated, rigid, and at times 
show calcareous deposits; or are bound together by 
adhesions. At times the obstruction is lower down, 
when it is in the form of a ventricular endocarditis. 
Again, the obstruction results from endocarditis of 
the pulmonary artery or from aneurysm or enlarged 
bronchial glands pressing on the pulmonary artery. 
If the condition has prevailed for some time, it is 
accompanied by hypertrophy of the right ventricle, 
tricuspid incompetence and dilatation of the right 
auricle. 



l66 PULMONARY STENOSIS. 

Symptoms: — There are no constant subjective 
symptoms. In those cases that are congenital, cya- 
nosis is often present; but in other cases it is not 
marked ; the eyes are often prominent ; the lips 
thick; fingers clubbed and superficial feeling con- 
gested. 

Inspection: — This does not reveal any sign that 
is constant. 

Palpation: — A distinct systolic thrill may be 
felt over a considerable part of the precordia. 

Percussion: — This may outline an enlarged 
heart transversely. 

A uscultation : — Reveals a systolic murmur at 
the base of the heart, its greatest intensity being in 
the second left intercostal space, close to the ster- 
num. It is superficial, limited in its diffusion and 
not transmitted to the vessels of the neck. 

Diagnosis : — This to a great extent is by exclu- 
sion. The murmur is not conveyed to the vessels 
of the neck, as it is in disease of the aortic orifice; 
neither has it the characteristic pulse, nor the 
hypertrophy of the left ventricle. When its form 
is congenital it is attended by clubbing of the fin- 
gers. It is practically impossible to distinguish, by 
the murmur produced, this lesion from the pres- 
sure on the pulmonary artery or aneurysm of the 
sinus of valsalva. 

Prognosis: — This is not good; most of these 
cases die young. Many of them develop pulmonary 
tuberculosis. 

Treatment: — This embraces the care of the 
lungs, and the prevention of pulmonary tuberculosis. 

See Therapeutics of Chronic Endocarditis. 



CHAPTER XX. 
TRICUSPID INCOMPETENCY. 

Definition : — This is a diseased condition of the 
tricuspid valve that allows the blood to pass back 
into the right auricle during cardiac systole. 

Etiology: — It is met with more frequently than 
any other valvular affection; and is so common 
that it is looked upon as a physiological provision 
for the relief of the over-distended right ventricle. 
There is no doubt that here, as at the other 
orifice, acute, sub-acute and chronic endocarditis 
give rise to incompetency. Muscular changes that 
allow of dilatation of the right ventricle, or obstruc- 
tion of the pulmonary orifice that results in much 
the same condition, also favor it. Emphysema and 
fibroid changes in the lungs, and the remote effects 
of chronic bronchitis, as well as mitral lesions, by 
interfering with the natural currents of the blood; 
also favor its development; as do disease of the 
kidneys, pyrexia, toxic influence and malnutrition. 

Pathology : — In many of these cases there is 
thickening and induration of the cusps, which may 
undergo a fibrinous or calcareous degeneration, 
while early in life vegetations develop on the cusps. 
In a larger percentage of cases, the valves do not 
show any change, but there is dilatation of the 
orifice. The right auricle is often dilated to a 
great extent, its walls being thinned. The dilata- 
tion is not confined to the auricle, but both the 
superior and inferior vena cava also show it. Those 
veins that are tributary to the inferior vena cava, 
having no valves, suffer most; as a result, the 



l68 TRICUSPID INCOMPETENCY. 

liver is enlarged and a nutmeg liver may result. 
The spleen is enlarged; there is congestion of the 
stomach; hemorrhoids; a general venous stasis; 
sub-cutaneous edema and mucous catarrh. 

Symptoms: — The symptoms are such as result 
from a passive congestion of the lungs and a dis,- 
tension of the venous system; as indicated by the 
dyspnea, palpitation, headache, vertigo, dizziness and 
gastric disturbance which are often severe. The 
skin is inclined to be jaundiced. The kidneys 
secrete but little urine and that is high colored. 
Constipation is often present, and dropsy, with or 
without ascites. 

Inspection: — The most marked symptom, and 
one that is considered pathognomonic, is venous 
pulsation. This is seen in the jugular veins when 
the patient is reclining. There is also a general 
venous congestion. The veins fill by jets that cor- 
respond to the heart beat. If a vein is emptied by 
passing a finger along its course from the centre 
towards the periphery it will be seen that the ven- 
ous blood is forced along behind the finger, refill- 
ing the vein. Undulation of the epigastrium due to 
the enlarged right ventricle is present. 

Palpation: — This confirms inspection, and by 
having the patient lie on the back with the arms 
raised; placing one hand over the right middle axil- 
lary region and the pther over the upper abdomen, 
the pulsation of the hepatic veins may be detected. 

Percussion : — This shows the heart to be en- 
larged to the right, with increased hepatic dullness. 

Auscultation: — There may be no murmur pres- 
ent. The murmur when present, is systolic in 



TRICUSPID STENOSIS. 169 

rythm, of a soft, blowing character and heard with 
the greatest intensity at the junction of the fifth 
and sixth left intercostal cartilage with the sternum. 

Diagnosis : — The most positive signs of tricuspid 
incompetence are, an acutal venous pulse and pul- 
sation of the liver; and other points are, the exten- 
sion of the cardiac dullness to the right and the 
systolic murmur over the tricuspid valve. 

Prognosis: — This is dependent on the cause of 
the disease. In those cases where it is dependent 
upon some disorder of the myocardium, or tempo- 
rary interference with the lungs; that are remov- 
able, it is good. It is markedly otherwise when it 
is the result of disease of the left side of the heart. 

Treatment : — When the disease results from 
valvular, pulmonary or myocardial disease it must 
be corrected. If due to faulty digestion this must 
be removed. 

See Therapeutics of Chronic Endocarditis. 

TRICUSPID STENOSIS. 

Definition: — This is a diseased condition of the 
tricuspid valve, interfering with the current of blood 
passing from the right auricle to the right ventricle. 

Etiology: — Tricuspid stenosis, as an isolated 
lesion, is very rare, being most frequently associated 
with mitral stenosis. It may be congenital or 
acquired; and has been recognized oftener in women 
than in men. When congenital, a defect of the 
septum ventriculorum is often present; while in 
acquired cases, there is usually a history of rheu- 
matism or chorea. 

Pathology • — The changes here are similar to 



I70 TRICUSPID STENOSIS. 

those found at the left orifice. There may be a 
union of the cusps that results in a funnel shape of 
the orifice. There is at the same time a degree of 
contraction and rigidity of the cusps, with a deposit 
of inorganic salts. Dilatation, with a degree of 
hypertrophy, is present in the left auricle, and 
venous stasis is noticed. 

Symptoms: — The subjective symptoms are not 
pronounced. Dyspnea is at times marked and is 
associated with chilliness of the extremities and 
susceptibility to cold. C} T anosis and cardiac palpita- 
tion is present in a varying degree. The com- 
plexion is dusky; the lips, nostrils and ears are 
dark. The distended condition of the veins indi- 
cate venous stasis and edema appears sooner or 
later. The urine is scanty, high colored and con- 
tains albumen. 

Inspection: — Shows a distended condition of the 
jugular veins with little or no pulsation; if pulsation 
is present it is presystolic. 

Palpation: — This may not reveal anything of 
a diagnostic value, but a presystolic thrill may be 
felt over the right auricle. 

Percussion : — May outline an enlarged right 
auricle. 

Auscultation: — When it can be recognized, there 
is a presystolic murmur, having its maximum in- 
tensity over the tricuspid area (beneath the sternum 
at the level of the fourth rib). In many cases no 
murmur is detected and when present, it will be 
found difficult to differentiate this from mitral 
stenosis, with which it is associated in about 80 
per cent of the cases. 



TRICUSPID STENOSIS. l7l 

Diagnosis: — It should be remembered that the 
secondary symptoms of mitral stenosis simulate 
those of tricuspid stenosis. But the presystolic 
murmur in tricuspid stenosis has its maximum in- 
tensity over the tricuspid area. 

Prognosis : — This depends on the extent to which 
other parts of the heart are implicated. 

Treatment : — As this lesion diminishes the 
amount of blood passing to the lung, and also, by 
retarding the venous blood which results in stasis;; 
care must be taken of these parts to favor their 
function as far as possible. 

See Therapeutics of Chronic Endocarditis. 



CHAPTER XXI. 
CARDIAC THROMBOSIS. 

This is an ante mortem coagula within the 
heart, which may develop rapidly or slowly. The 
former is termed heart clots or thrombi; the latter, 
from the fibrinous deposits that take place, is 
called cardiac polypi. 

Etiology: — In the majority of cases there has 
been some cause at work, weakening the heart's 
action, and as a result the blood current is re- 
tarded; associated with this is some obstruction to 
the blood current, as is seen in pneumonia. These 
conditions may be brought about by the various 
degenerations of the myocardium or changes in 
the endocardium, as erosions and ulcerations, when 
associated with a toxic condition of the blood. 
Cardiac aneurysms and valvular aneurysms, valvu- 
lar stenosis, especially of the mitral valve, are 
occasional causes. 

Pathology : — The distinction between ante mor- 
tem and post mortem, or immediate ante mortem 
clots should be clear to everyone making autop- 
sies. Recent clots may have the color of the 
blood; but more frequently they have but little of 
the coloring matter of the blood, and are a straw 
color, may be translucent, soft and gelatinous. 
When lifted from their seat they are easily de- 
tached without any rupture, although they are 
friable. True cardiac thrombi are formed by a 
gradual deposit of fibrin on some roughened point 
where the blood is retained, as in the apex of the 
ventricles. The thrombi are of a dull, grayish 



CARDIAC THROMBOSIS. 173 

white color and are firmly attached to the cardiac 
wall; either by a broad surface or by a mere stem. 
They vary in size and may completely fill the ven- 
tricle. 

Symptoms : — These vary, accordingly as the 
thrombosis forms slowly or rapidly and according 
to its location. When it appears suddenly in con- 
nection with pneumonia or other pulmonary dis- 
ease, the dyspnea, cyanosis and venous turgescence 
are all increased; as well as the frequency of the 
heart; which becomes irregular in action; a sys- 
tolic murmur is apt to develop in the right side 
of the heart; the respirations become gasping in 
character; a deep cyanosis appears; there is coma 
and death. In the more chronic form the symp- 
toms are not as marked, and frequently it gives rise 
to no symptoms until it interferes with the heart's 
action; when it is found to be disturbed both in 
rhythm and force, it is irregular and intermits; a 
murmur is frequently present that may be systolic 
or diastolic, but possesses no distinct character- 
istic. When confined to the left heart there is 
always a danger of cerebral embolism. 

Diagnosis : — When they develop slowly they 
cannot be recognized with certainty. In the acute 
forms, the appearance of all acute systemic shocks, 
cardiac obstruction and development of a systolic 
murmur is significant. 

Prognosis : — This is unfavorable; acute throm- 
bosis usually proves fatal within a week, and the 
chronic forms do not disappear. 

Treatment : — In the acute form absolute rest is 
to be insisted upon. The dyspnea is best con- 



1 74 ANEURYSM OF THE VALVES. 

trolled by inhalations of oxygen and glonoine. 
Strychnia will be of service if extreme cyanosis 
and irregular heart action appear. In cases of ir- 
regular respiration, belladonna or atropine will be 
found beneficial. To arrest the development of 
the thrombosis, the aromatic spirits of ammonia 
have been used extensively, and other preparations 
of ammonia are good cardiac stimulants. Should 
other cardiac stimulants' be desired, caffeine and 
strophanthus are to be preferred to digitalis. 

ANEURYSM OF THE VALVES. 

This usually results from malignant endocar- 
ditis or some degenerative process. It may pro- 
ject from either the aortic or mitral valve into the 
left ventricle or auricle. The sac may rupture and 
valvular insufficiency result. The symptoms are 
not definite as they are often associated with those 
due to other cardiac lesions. 

A diagnosis is seldom, if ever, made during 
life. 

The treatment must be symptomatic. 



CHAPTER XXII. 
ARRHYTHMIA. 

This is an irregularity of the heart's action, 
either in volume or in rhythm. Whenever the 
pulse manifests irregularity it is advisable to 
examine the heart's contractions by auscultation 
and to compare them with the pulse. At times it 
will be found that feeble ventricular contractions 
do not produce a pulse beat. In view of these 
facts the heart rate and pulse rate should always 
be taken. 

Pulsus Alternans — In this form the intervals 
between the beats may be regular, but a full and 
strong beat alternates with a weak one. This 
condition may be more marked and a beat 
dropped altogether at regular or irregular inter- 
vals. 

Pulsus Bigeminus: — In this case there are two 
beats close together which are followed by two 
that are farther apart. Instead of being in twos 
they may be in groups of three (pulsus trigeminus) 
or four (pulsus quadrigeminus). This is observed 
in some cases of mitral disease. 

Pulsus Paradoxus: — Is a condition in which 
the pulse is more rapid but weaker during inspira- 
tion than expiration. This is noticed in weak 
hearts, where there is an adherent pericardium, or 
pressure from inflammatory bands about the arch 
of the aorta. 

Delirium Cordis: — Is an irregularity of the 
heart in which several beats come together and is 
then followed by a short period of rest, then one 



176 ARRHYTHMIA 



or two normal contractions, and then another par- 
oxysm of delirious contractions. This has been 
noticed during bronchial asthma, marked dilatation 
of the heart and the last stages of exophthalmic 
goitre. 

Tremor Cordis: — Is an irregularity in which 
the heart, without apparent cause, takes on a rapid 
tumultuous action, which continues for a few 
seconds and is followed by an intermission of the 
pulse and then a forcible beat; after which there 
is the usual rhythm. This is observed in the weak 
and debilitated, who suffer from flatulence and 
gastric disturbances. 

Gallop Rhythm: — Is when the heart's sounds 
simulate those produced by the hoofs of a gallop- 
ing horse. There is a reduplication of the second 
sound. It is met with in chronic nephritis, 
anemia, typhoid, pneumonia, etc. 

Etiology: — Among the direct causes of arrhyth- 
mia are meningitis, lesions of the brain, pressure 
upon the nerve trunks that supply the heart, 
structural disease of the heart, and conditions that 
interfere with the heart's functions. Of the reflex 
causes are irritation from the abdominal organs. 
Shock, traumatism and toxic condition, the result 
of poisons either generated within the body or 
introduced from without, are also causes. 

Symptoms; — As the term arrhythmia implies, 
these are indicated by the irregularity of the 
heart's action, which may consist of a simple inter- 
mission at regular or irregular intervals. In other 
cases, there may be a reduplication of a beat or 
partial suppression of certain contractions. The 



ARRHYTHMIA. 1 77 



beats may be at long- or short intervals; bound- 
ing or feeble and faint. The patient may, or may 
not, be conscious of the irregularity. When con- 
scious of it there is usually no real distress, but 
there may be a feeling of insecurity and occasion- 
ally of pain. 

Diagnosis: — This is ascertained in the exam- 
ination of the patient. The sphygmograph is 
of great service in differentiating dicrotism from 
arrhythmia. If possible, reflex arrhythmia should 
be distinguished from that due to structural 
changes. 

Prognosis: — This depends upon the form of 
the arrhythmia present. Regular arrhythmia, that 
noticed among children when sleeping; or when 
accompanying indigestion and dependent upon 
alcohol, tobacco, tea, coffee, are all favorable to 
life and many are relieved by removing the cause. 
While in those dependent upon Bright's disease, 
gout, cardiac degeneration and the acute infectious 
diseases, the prognosis is not so good. 

Treatment: — In many of these cases it is im- 
possible to accomplish anything permanent, as the 
arrhythmia is dependent upon some deep seated 
disease. In those cases where the cause is to- 
bacco, alcohol, tea; coffee or indigestible food it 
should be removed. In all cases it is the primary 
disease that must be studied, and the remedy 
chosen with that in mind. 



CHAPTER XXIII. 
PALPITATION. 

This is an increased action of the heart both 
in force and frequency that causes the patient 
distress. 

Etiology: — It is observed more in the young 
than in the aged, and in those who are anemic 
and suffer from reflex gastro-intestinal causes, and 
emotional and mental disturbances during the 
climacteric period. The toxic condition of the 
blood — the result of the infective disease, has 
often been noticed as a cause, as well as alcohol, 
tobacco, tea, and coffee. Regarding the sexes, 
the female suffers most during puberty and the 
menopause; while in the male it appears most 
during the middle and later period of life; when 
worry and business care are heavy. Hypertrophy 
of the heart is frequently a cause of palpitation. 

Symptoms: — It is usually paroxysmal, being 
seldom constant. Preceding the attack there is a 
slowing of the heart's action and a pallor of the 
skin. This is followed by a sense of an increased 
force and rapidity of the heart with mental anxiety 
of dyspnea. 

Physical Signs : — There is seen a throbbing of 
the vessels and the cardiac impulse is diffused. 
The pulse is rapid, full and strong (110 to 150). 
The area of cardiac dullness may be enlarged. 
The valvular sounds are more distinct than is 
natural. 

Cardiac palpitation should not be mistaken for 
those forms where there is great rapidity and ir- 



PALPITATION. 179 



regularity of the heart's action without the patient 
knowing it. The palpitation due to valvular dis- 
ease should not be mistaken for that due to ner- 
vous derangement. 

Prognosis : — There is no real danger in itself 
but hypertrophy may ensue. 

Treatment: — To arrest the attack the patient 
should be placed in bed where it is quiet and all 
clothing loosened over the precordial region. In 
some cases cold, while in others hot drinks re- 
lieve it. 

Aconite: — This remedy is indicated when the 
palpitation is the result of fright, excessive physi- 
cal exertion, functional or structural disease of the 
heart, lungs or stomach; in young, plethoric, 
robust individuals with an excitable temperament. 

Arsenicum alb. : — Violent palpitation of the 
heart, the paroxysms being worse just after mid- 
night. They are often accompanied by a paroxysm 
of nervous asthma and are attended with great 
restlessness and anxiety. There is frequently a 
periodicity about the attacks in those who are 
chlorotic and addicted to the excessive use of 
alcohol. 

Arsenicum iod. : — This remedy should be 
studied where the arteries and heart show indica- 
tions of degeneration. 

Nux vomica: — This remedy is often indicated 
when the palpitation is the result of a deranged 
stomach, liver or bowels, or from the abuse of 
alcohol, tea, coffee, or the result of excessive 
study. 

Spigelia: — When this remedy is indicated there 



l8o PALPITATION. 



is violent palpitation which is audible to the 
patient. The action of the heart is irregular both 
in rhythm and impulse, giving it an undulating 
motion. The palpitation is associated with shoot- 
ing pains about the heart, rheumatism and in- 
testinal worms. 

Cinchona: — When palpitation appears as a re- 
sult of debilitating losses from diarrheas and hem- 
orrhages or fevers, study this remedy. 

Ignatia: — When violent emotions or grief is 
acute; also, asafcetida, nux moschata and cocculus. 

Pulsatilla: — This remedy is to be thought of 
when palpitation appears as a result of menstrual 
derangement, or when fatty food has been taken. 

Ferrum: — This remedy is adapted to anemic 
patients. The face changes color frequently and 
is red at the beginning of an attack. These 
patients are often tubercular; are easily excited, 
and if females, the menses are scanty and uterine 
catarrh is present. 

Digitalis: — We have no remedy so frequently 
indicated in palpitation resulting from self abuses 
as this. It not only relieves the palpitation but 
it also diminishes and arrests the nightly emissions 
that so frequently accompany it. 

Cannabis sat. : — This remedy should be thought 
of in those cases of palpitation of the heart that 
are the result of self abuse. It is second only to 
digitalis in the relief of the palpitation from this 
cause and in its control over the sexual excite- 
ment. 

Coffee: — The palpitation is strong and visible; 
the patient is restless and weary, yet cannot sleep. 






PALPITATION. 101 



Calcarea carb. and sulphur: — Should be studied 
in chronic cases. 

Chamomilla and Opium, for cases that are the 
result of fright. 

Platina: — In cases of menstrual irregularity, re- 
tention of the menses and in cases of great sexual 
excitement. 



CHAPTER XXIV. 
BRADYCARDIA. 

This is the term applied to a slowness of the 
pulse. It is generally conceded that the pulse 
must be as low as 40 to the minute before the 
term bradycardia applies. 

Etiology : — A slow pulse is characteristic in cer- 
tain families and in those who have perfect con- 
trol of themselves and are not easily excited. It 
may be permanent, paroxysmal or temporary. 
When permanent, it is frequently dependent upon 
a structural disease of the brain in which the 
pneumogastric nerve is irritated; as is seen in 
traumatism, pachymeningitis and cerebro-spinal 
meningitis, hydrocephalus and epilepsy. Tempo- 
rary bradycardia is often observed after typhoid 
fever, diphtheria, pneumonia, erysipelas, during 
jaundice and from intestinal toxines. The parox- 
ysmal form appears during depression of the ner- 
vous system and disappears as that returns to a 
normal standard. 

Pathology : — In many of these cases myocardial 
degeneration has been found. Of these the fibroid 
is more frequently met with than the fatty; while 
sclerotic changes of the arteries of the brain are 
frequently associated. 

Symptoms: — The pulse rate is reduced, and 
during the recurrent attacks, so markedly, that it 
may be down to five. Giddiness, faintness, un- 
consciousness and breathlessness are often present 
in varying degree. Pallor, while not constant, is 
often observed. The arteries are rigid and tortu- 



BRADYCARDIA. 183 

ous and are often below normal. The area of 
cardiac dullness is usually increased. If hyper- 
trophy be present, the first sound is long and 
low; if dilatation be present, it is short and 
sharp. Dyspnea is common and the Cheyne- 
Stokes respiration is often present during the 
paroxysm. The urine is scanty. Cerebral symp- 
toms, differing in the degree of their intensity, 
are present during these periods of rare pulsation. 

Diagnosis: — This is based on the permanency 
of the diminution of the pulse, and the paroxysms 
of still greater infrequency. This should not be 
mistaken for those conditions in which there is 
temporary infrequency of the pulse. 

Prognosis: — This depends upon the cause; 
where this is amenable to treatment, the prognosis 
is good, but when due to some structural lesion 
it is unfavorable. 

Treatment: — The general condition of the 
patient must be improved, and the cause sought 
out and if possible removed. If dependent upon 
jaundice it must be corrected, as well as intestinal 
toxines, tobacco, alcohol, coffee, tea or uremic 
poisoning. 

Cannabis indica: — This remedy produces a very 
slow pulse, but the mental and nervous symptoms 
are present when it is indicated. 

Ascelpias cornuti: — The pulse is very slow and 
the patient is subject to violent nervous headaches, 
the pain being most marked between the eyes. 
The headache is often produced by the suppression 
of a perspiration. There is violent vomiting with 
soft, yellow, bilious stools. 



184 BRADYCARDIA. 



Digitalis:— When this remedy is indicated there 
is usually some form of organic heart disease. 
The pulse is slow but may become irregular, or 
intermittent, and excited by the least movement. 
There is a sensation as if the heart would stop 
beating if he moved. 

Opium: — The pulse is slow and full with de- 
pression on the cerebral function, as indicated by 
the drowsiness and stupor, the respirations are 
slow, stertorous and puffing. 

Paris quadrifolia: — This remedy produces a 
slow but full pulse, especially when due to spinal 
affections as the result of traumatism. Thinking 
aggravates the pain in the occiput. The eyes feel 
large as if the eyelids would not close over them, 
or as if a thread drew them back into the head. 



CHAPTER XXV. 
TACHYCARDIA. 

This is a recurrent, paroxysmal, rapid and 
forceful beating- of the heart that is usually not 
recognized by the patient. 

Etiology: — In the majority of cases paralysis of 
the vagus, irritation of the sympathetic, or affec- 
tions of the cardiac ganglia is present. Hysteria, 
anemia, chlorosis, tea, coffee and tobacco are often 
among the exciting causes; as are rheumatism, 
influenza, diphtheria, mental excitement and gastric 
disturbance. 

Pathology : — It should be remembered that the 
pulse rate is normally high (ioo), with some indi- 
viduals; while others can increase its rate at will. 
The neurotic condition in some of its various 
forms is observed in many of these cases; while 
in others, more serious lesions are present which 
lead to paralysis of the vagus; as tumors, clots, 
aneurysms and enlarged glands. It may be pro- 
duced by reflex irritation from the ovaries, uterus 
or intestinal tract. 

Symptoms : — In the majority of cases there are 
recurrent paroxysms of the tachycardia. The 
attack may appear at any time, suddenly and 
without any warning; occasionally a slight vertigo 
or tinnitus may be complained of. The patient 
becomes pale, cyanosis may be present, and a 
pulsation of the carotid arteries or jugular veins 
noticed. The cardiac movement is greatly accel- 
erated and may be anywhere from 150 to 300 to 
the minute. The pulse is nearly always feeble, 



1 86 TACHYCARDIA, 



irregular, small, and frequently it cannot be counted 
at the wrist; when auscultation must be resorted 
to. These pulsations are maintained at the same 
ratio night and day. Respiration is not changed to 
any marked degree. While uneasiness and at times 
pain may be complained of, it is not the rule; for 
in the majority of cases, the patient is not conscious 
of any accelerated heart action and may even have 
a sensation of slowness of the heart. Upon physical 
examination the area of cardiac pulsation is in- 
creased, while its force is diminished. There is a 
varying degree of pulmonary hyperemia present, 
with subcutaneous edema and albumen in the urine. 

Diagnosis: — This is based on the high pulse 
rate, and the absence on the part of the patient of 
any sense of rapid heart or palpitation. It must be 
differentiated from palpitation. In palpitation the 
pulse rate is not so high, and there is dyspnea 
and smothering, precordial distress. 

Prognosis : — The course of this disease is chronic 
and recoveries are rare. If the cause be such as 
can be removed, it may be cured, but not always. 
It should be remembered that a cerebral vessel is 
liable to rupture during an attack. 

Treatment : — This is dependent upon the cause 
and the possibility of its removal. When due to 
reflex causes, just as the part involved is relieved, 
so will this disappear. If from exhaustion of the 
nervous system, this must be given rest and the 
nutrition improved. If due to fright or some 
emotion, a complete change of scenery and sur- 
roundings are often of benefit. Any excess in tea, 
coffee, or tobacco should be stopped. If the result 
of cardiac degeneration, baths and systematic exer- 



TACHYCARDIA. 187 



cise are frequently of benefit; if there is an actual 
degeneration of the nervous structure, treatment is 
not beneficial. During an attack, firm pressure 
upon the thorax is often of assistance. 

The power of suggestion should be remembered 
and used in the treatment of this class of patients. 
Some patients can ward off an attack by taking a 
deep inspiration and holding it as long as possible. 
All forms of cardiac tonics should be avoided un- 
less cardiac dilatation or weakness be present. 

Aurum mur. : — Where there are evidences of 
myocardial degeneration, this remedy given in the 
2X for a long period is often of service. 

Spartine sulphate ix: — One grain every hour is 
often beneficial in myocardial degeneration of neu- 
rotic subjects. 

Ammonium valer: — This remedy is indicated in 
neurotic and hysterical patients, who are suffering 
from nerve exhaustion; the heart being weak and 
erratic. 



CHAPTER XXVI. 

ANGINA PECTORIS. 

This is a disease characterized by excruciating 
pains in the cardiac region, a sense of utter power- 
lessness, and fear of impending dissolution. It has 
been divided into two varieties, the true and false. 

Etiology: — True angina is most frequently met 
with in males who are past forty years of age. A 
large proportion of these cases show fatty degener- 
ation of the heart, with sclerosis or calcification of 
the coronary arteries; while in other cases it has 
appeared to depend upon aortitis, adherent pericar- 
dium, cardiac hypertrophy, aortic regurgitation or 
stenosis, and arterial sclerosis. In certain families 
there appears to be a hereditary tendency to 
development of such conditions as produce these 
paroxysms. Derangement of the alimentary canal, 
dilatation and distention of the stomach, and 
toxic agents as tobacco, tea, coffee and alcohol 
have each at times been recognized as causes; in 
many, the attacks are precipitated by over exertion 
or some pronounced mental emotion. The pseudo 
angina occurs in neurasthenics or the hysterical, 
during the early part of life and is frequently 
associated with uterine or ovarian irritation, dys- 
menorrhea and salpingitis. 

Pathology: — It should be remembered that 
angina pectoris is a neurosis, no definite pathologi- 
cal change being constant, and yet structural changes 
are so frequently associated that they demand atten- 
tion. | Among these changes are interstitial myocar- 
ditis with arterial sclerosis, especially of the coro- 



ANGINA PECTORIS. 1 89 



nary arteries, as well as fatty degeneration, and 
gummata with its attendant fibroid changes. Apart 
from the sclerosis as already mentioned, endarteritis 
deformans and obliterans have their influence, espec- 
ially as they affect the nutrition of the heart. With 
this group should be placed structural changes in 
the aorta and coronary arteries and occlusion of the 
openings of the latter. Neuritis of the cardiac 
plexus of nerves has been demonstrated in a few 
cases. 

Symptoms: — True angina pectoris begins sud- 
denly, usually during some mental emotion or 
marked exertion. The patient is seized with a 
most excrutiating pain which is griping in charac- 
acter, rendering the body motionless and involving 
the whole chest. The pains radiate to the left 
shoulder and arm, at times the right is involved; 
the pains may be felt in the neck and back and 
accompanied by a sensation of coldness and numb- 
ness, and a sense of impending death. The counte- 
nance becomes pale and is bathed in a cold per- 
spiration. The respirations are shallow, but the 
patient can breathe deeply. The heart's action may 
be regular and the arterial tension is usually in- 
creased. The duration of the attack varies from a 
second or two to an hour or longer, and is fol- 
lowed by eructation of gases, vomiting or passage 
of large quantities of pale urine. 

The pseudo angina occurs most frequently in 
females of the hysterical and neurasthenic type, who 
suffer from derangement of the uterus and its ap- 
pendages. There is frequently symptoms of disturb- 
ance of the vaso-motor system. Careful examina- 
tion reveals the hysterogenic spots and anesthetic 



I9O ANGINA PECTORIS. 



area. The recurrence of the attack varies; it may 
return at any time, or months and years may inter- 
vene. If the patient is careful not to become ex- 
hausted and is of a calm disposition, the intervals 
between the attacks may be lengthened. It has 
been observed that as dilatation of the heart takes 
place, the attacks become less frequent and less 
severe. 

Diagnosis: — This is dependent upon: the pain 
which comes quickly, is most severe in and con- 
fined to, the region of the heart, and radiates to 
the shoulder; the mental anxiety; and the inability 
of the patient to move. He is past the meridian 
of life and is apt to present indications of circu- 
latory disturbances. 

Pseudo angina is seen most frequently in hyster- 
ical and neurasthenic females; the attack is often 
produced by some emotion. The patient does not 
keep quiet, and the pain may radiate all over the 
body. Neuralgia of the heart is found from 
tobacco and alcohol, but there is the odor and 
other evidences pointing to these as the cause. 
Lead poisoning is indicated by the abdominal colic, 
the blue line on the gums, and the constipation. 
Intercostal neuralgia and cardiac asthma should be 
remembered as they have been mistaken for angina 
pectoris. 

Prognosis : — In real angina this is always grave; 
especially if there is arterial sclerosis, disease of the 
valves, or myocardial degeneration. If fatty accu- 
mulation is the cause, the prognosis is more favor- 
able. In those cases where it is dependent upon a 
toxic condition, its removal renders the prognosis 
better; in those cases where it is due to neurotic 



ANGINA PECTORIS. IQI 



condition, recurrence is common, but it does not 
kill. 

Treatment: — If anything permanent is to be 
accomplished by treatment, a most careful examina- 
tion of the individual case must be made. Not the 
attack alone, but the habits of the patient, his 
family history and environments must all be studied 
in every possible light. In the management, each 
case must be considered separately and the causes 
that excite an attack sought after. Man} 7 of these 
patients already have recognized the cause in their 
own case and often it is some irregularity of diet, 
exercise or mental condition. Many times it is not 
an easy matter to control the mental state, as the 
worry and strain of business life presses upon many 
of these patients, and is responsible for many cases 
of arterial degeneration that give rise to apoplexy, 
Bright V disease, aneurysm or angina pectoris. The 
age and occupation of the patient, and the condi- 
tion of the vascular system should be taken into 
consideration. 

Following an attack the condition of the heart 
may require absolute rest, from a day to a week or 
more; this is especially true if the attacks are pre- 
cipitated by slight degree of exercise, which shows 
that the heart is not able to propel the blood under 
anything but normal conditions. Under no condi- 
tion should quick movements and strong emotions 
be associated. Steady quiet exercise as walking 
upon level ground is beneficial. If the cardiac 
weakness is such as to forbid this, massage, or the 
resistance exercise of the Schott's method may be 
tried. This exercise should not follow immediately 
after a meal. 



I92 ANGINA PECTORIS. 



In many of these cases the diet is most import- 
ant. Generally they are good feeders on rich and 
strong food. First the quantity must be reduced, 
for the great majority eat too much. All food 
that distresses the patient in any form should be 
forbidden, especially those that give rise to flatu- 
lence. In cases where there is marked indication 
of atheroma and calcification of the arteries, those 
articles of food that contain an excess of lime, as 
milk, eggs, cheese, etc., should be eliminated so far 
as possible. In those cases that are known as false 
angina, the neurasthenia and hysteria must be over- 
come; at times a positive diagnosis that no serious 
heart lesion is present, is of great benefit to the 
patient. In many of these cases the Weir Mitchell 
treatment, systematic massage, and static electricity 
is of service. Some patients know of an approach 
of an attack due to some indiscretion in diet, and 
take steps to relieve the stomach of the offending 
meal. 

During an attack, a pearl containing five drops 
of the nitrate of amyl should be broken on a towel 
and the vapor inhaled. This drug will give better 
results in cases of true angina than in the false 
form. One or two drops of the first centesimal of 
glonoine by the mouth, will often cut an attack 
short. It is advisable to let the patient have one 
or both of these drugs with him, to be taken in an 
emergency, for it is seldom that a physician can 
reach the patient in time to render any service dur- 
ing the attack. In giving the patient these drugs 
he should be warned of the dangers from them. 
Chloroform has been employed, but its first action 
is slow, as is opium and its alkaloid morphine. In 



ANGINA PECTORIS. I93 



pseudo angina, magnesia phos. in hot water, a dose 
every three to five minutes will often bring relief. 
Cold applications to the chest or swallowing pieces 
of ice have been known to break the paroxysm. 

Natrum iod.: — This remedy in from five to 
twenty grains three times a day, will be found to 
give most excellent results where there is organic 
disease of the heart, associated with the angina 
pectoris. There is an oppression in the region of 
the heart that is attended with a fear of death and 
a feeling as if something dreadful was about to 
happen. 

Kali iod.: — Severe pains in the centre of the 
chest which extends to the shoulder. The pains in 
the chest are very severe; the patient desires to get 
into the fresh air; there is oppressed breathing and 
loss of voice. 

Spongia: — There are sudden cramping pains 
within the chest with oppressed breathing and sen- 
sation of suffocation. The face is pale, a feeling of 
nausea is complained of. The lower portion of the 
body feels numb while the upper portion is sore. 

Cactus grand: — When with the angina pectoris 
there is an organic lesion. There is a sensation as 
if the heart were grasped by an iron band prevent- 
ing its normal movements; with a continuous palpi- 
tation of the heart, which is aggravated by walk- 
ing, and at night when lying on the left side. 

Arsenicum: — When the attacks are periodical, 
are attended with faintness and extreme weakness, 
worse after midnight and from motion. There is 
great mental and bodily anxiety with severe pain 
that extends down the arm, and great prostration 



194 ANGINA PECTORIS. 



and dyspnea; the surface of the body is cold, and 
there is marked prostration following the attacks. 
Spigelia: — There is constriction and painfulness 
in the left side of the chest which arrests the 
breathing and causes a sensation of suffocation. 
The palpitation of the heart is pronounced and the 
pains are aggravated by motion and leaning for- 
ward. 

Cuprum:- — Where there is but little vitality; in 
feeble individuals, with slow pulse that have suffered 
during a long period. The attacks appear suddenly, 
are attended with great dyspnea, the surface of the 
body is cold and blue and there is a tendency to 
cramps. 

Laurocerasus: — In recent cases where there is 
marked structural lesion. The attacks are severe, 
are attended with great suffering, gasping for breath 
and loss of speech. The skin is moist and cold. 

Aurum mur. :— The attacks are precipitated by 
walking in the open air; the palpitation begins and 
grows worse, and the pain more severe while in 
the open air; but relief is found by going to a 
closed room where the patient can walk for an 
indefinite period with no discomfort. 

Veratrum alb. : — This remedy will be found of 
service in functional cases where there is a feeling 
of impending suffocation, with constriction of the 
chest and cutting pains that arrest the breathing. 

Tabacum: — When this remedy is indicated there 
is an intermittent pulse, pallor with cold, clammy 
perspiration, vertigo and deathly nausea. There are 
accumulations of white tenacious mucus in the 
mouth, and great thirst with deathly nausea and 



ANGINA PECTORIS. I95 



vomiting, which comes in paroxysms and is made 
worse by motion. The stomach feels relaxed as if 
sinking in. There is violent palpitation of the heart 
with paroxysms of precordial oppression and pain 
between the shoulders. The pulse is feeble, soft, 
slow and intermittent. The patient complains of 
great weakness and debility, is restless and desires 
to change his position often. 

Lilium tigrinum: — This remedy will be found of 
service in nervous affections of the heart. The 
patient is usually of the female sex and suffers from 
ovarian and uterine diseases. She is depressed in 
spirits and inclined to weep. She feels that things 
must be done at once but is unable to perform the 
task, and mental irritation results. The abdomen is 
distended, and there is such a dragging downwards 
of the organs of the abdomen and chest that she 
supports the abdomen with her hands. She is a 
subject of morning diarrhea, when there is great 
pressure in the rectum and a constant desire to go 
to stool. There is a constant desire to urinate, 
which is worse during the day; the discharge is 
scanty and is followed by a burning and smarting 
in the urethra. There is a sensation as though the 
pelvic organs would press through the vulva, with 
sharp pains in the ovarian region; she finds relief 
by pressing the hand against the parts. A constant 
distress about the heart is complained of with sharp 
quick pains, also a fluttering and palpitation of the 
heart and a feeling as if it was squeezed in a vise, 
or was alternately grasped and relaxed. Her limbs 
are cold, with burning of the palms of the hands 
and soles of the feet. She is worse at night and 
finds relief during the day by keeping busy. 



I96 ANGINA PECTORIS. 



Nux vomica: — Should be studied in the gouty, 
hemorrhoidal patient, where it is so frequently indi- 
cated. 

Aconite: — In pseudo angina, has relieved when 
its characteristic symptoms are present, as well as 
digitalis and naja. 



CHAPTER XXVII. 
NICOTINE POISONING. 

This is the result either of working with or the 
use of tobacco; whereby the heart's action is func- 
tionally deranged. In mild cases, irregularity is 
noticed, with palpitation on exertion, the patient 
being aware of the heart beats. The long con- 
tinued over-excitement leading to disturbance in its 
rhythm and to cardiac hypertrophy. The pulse 
rate may be normal, but usually it is irregular. 
Anginal attacks are present in many of the well 
marked cases, while in others, there is precordial 
oppression. The patient complains of dizziness, 
with weakness and failing health: tremor of the 
hands and loss of strength. The appetite is poor; 
there is nausea and vomiting, with melancholy and 
depressed spirits. 

Physical Examination: — While it may reveal 
no definite cardiac lesion, there is usually a defi- 
ciency in some of the heart sounds; reduplications 
are often observed and the rythm is irregular. 
Murmurs are rare, but when present are functional 
and due to an altered tension of the heart muscle; 
a change in the force of the cardiac impact against 
the chest wall and anemia. They disappear with 
improvement of the general health. 

The greater part of the effects of tobacco, that 
interests physicians, is its action on the heart, nerves 
and throat. The results are functional, lessening 
the heart's power to stand work. Neurasthenia is 
a frequent result of prolonged smoking. 

Treatment : — The use of all tobacco must be 



I98 NICOTINE POISONING. 

stopped or modified under the physician's direction. 
The general health must be improved by a nourish- 
ing diet, baths, fresh air, etc. 

Nux vomica will benefit those of a malicious, 
irritable temperament; who fall asleep early in the 
evening and awake early in the morning. There 
is a bad taste in the mouth in the morning; the 
first half of the tongue is clean, the back part 
coated. The bowels are constipated, with frequent 
but ineffectual desire for stool. 

Ignatia amara: — This patient is full of silent 
grief and a sensation of goneness in the pit of the 
stomach. The bowels are inclined to be loose, with 
neuralgia of the rectum, which returns at regular 
intervals. 

Convallaria: — In tobacco heart, the result of 
cigarettes. Where there is dyspepsia with torpor 
of the stomach. The mucous membrane of the 
mouth is pale and flabby. The tongue is broad 
and thick, and is covered with a heavy, dirty white 
coating. 

Hydrocyanic acid: — Where there is much pain 
about the heart with rapid and irregular action. 
This remedy will relieve the irritable and irregular 
action, the result of the increased nerve force and 
over stimulation. 

Cactus grandiflorus: — There is irregularity of 
the heart's action with nervous excitement. The 
patient is debilitated, has indigestion and there is a 
feeling of an iron band about the heart preventing 
its normal action. 

Veratrum alb.: — For the bad results from chew- 
ing tobacco. 






WEAK HEART. £99 



WEAK HEART. 

This is a term applied to certain cardiac phe- 
nomena, characterized by a loss of energy, when it 
is impossible by physical methods to define any 
structural lesion. 

Etiology : — A percentage of these cases are con- 
genital; of the exciting causes are, pyrexia, alco- 
holic excesses, poor nutrition, loss of fluid, and also, 
a continual over-exertion. 

Pathology : — In some of these cases no lesion is 
discernible under the microscope; while in others, 
the muscle is relaxed and easily torn. At times a 
fibrillary, fragmentary, granular, or pigmentary 
atrophy is demonstrable. Undoubtedly, in some of 
these cases a myocardial degeneration is present. 

Symptoms: — In some cases the symptoms are 
over-shadowed by the disease, of which the weak- 
ness is a part. In others there is faintness, breath- 
lessness, giddiness and palpitation; with a small, 
empty pulse that may be slow or rapid and is 
usually irregular. The heart's action is feeble and 
the area of cardiac dullness normal, unless dilatation 
is present. The heart sounds are feeble especially 
the first. There is apt to be venous stasis, and as 
a result, interference with the function of various 
organs. Often a systolic murmur and impulse are 
to be heard and felt at the second left intercostal 
space. 

Diagnosis : — The condition of the pulse ; en- 
feebled cardiac muscle and the result of physical 
examination in general; the state of nutrition, 
bloodlessness, prexia, cachexia, etc., are the basis 
of the diagnosis. 



200 WEAK HEART. 



Prognosis: — This is dependent on the cause. 

Treatment: — This includes the removal of the 
cause and the employment of proper diet, rest, air, 
congenial surroundings, massage, baths and. exercise. 
The etiology of the cases is varied, and each must 
be understood before an intelligent treatment can 
be instituted. When the case is congenital, it will 
depend wholly upon the defect as to whether or no 
the treatment will be of much benefit. In all these 
cases the deep acting, constitutional remedies should 
be studied, as sulphur, the lime salts and silicates. 
When it is the result of some prolonged illness, the 
patient's heart should always receive a careful ex- 
amination before the patient is allowed to sit up. 
Frequently, calc. phos., or one of this group will 
be found of service. Should it be determined that 
an excess of alcohol or tobacco is the exciting 
cause, it must be stopped, or at least modified, and 
such remedies employed as will assist in repairing 
the damage. 

When poor nutrition is the exciting cause, this 
must be improved, not only by the diet, but by a 
change of climate, social surroundings and the em- 
ployment of such remedies as will assist the system. 
If there has been a loss of fluids and the loss is 
acute, the employment of normal salt solution should 
be used; if not so acute, the loss should be con- 
trolled and an abundant amount of easily digested 
and nutritious food should be employed, while such 
remedies as china, phosph., helonias and phos. acid 
studied. In those cases where there has been a 
continual over-exertion, there must be a let-up; such 
habits adopted as will not over-tax the organ, and 
at the same time allow it to regain its power. 



WEAK HEART. 201 



Nux vomica or ignatia is often of service when 
mental worry has been associated with the over- 
work. Arnica will be of service if there have been 
severe strains. If, with the weak pulse, there is 
faintness and vertigo, digitalis or Crataegus will be 
found serviceable. 

Phaseolus nana: — This remedy has been found 
of service in cases where the heart's action is very 
weak and irregular. There is a feeling of impending 
dissolution, with palpitation of the heart and general 
dropsy. The pulse is scarcely perceptible and is 
irregular. 

Antimon. ars.: — There is great weakness of the 
heart with excessive dyspnea and cough. 

Caffeine: — When, with the weak heart, there is 
marked exhaustion, the result of some prostrating 
disease. 

Kola: — In cases of weak heart, in those who are 
hysterical and in neurasthenics, where there are in- 
dications of cerebral anemia with melancholia. 

Kali ferrocyanatum : — This remedy will be found 
serviceable in cases of anemia with functional dis- 
orders of the heart, in which the heart is weak, 
and the pulse is weak and irregular. 

Zinc cyanide: — In cardiac neurosis where there 
is great sensitiveness with a bad temper and the 
patient is subject to attacks of anger. The face 
suddenly changes color; the heart is weak; there is 
frequently a spasmodic retching and gastral gas, 
which seems to be sympathetic. 



CHAPTER XXVIII. 

CONGENITAL HEART DISEASE. 

The product of reproduction may be affected 
during any period of its ante natal development. 
During the first period of existence, before the union 
of the germ and the sperm cell; also during the 
second period, from impregnation to the beginning 
of the development of the special organs; (at about 
the eighth week), any derangement leads to the 
development of fetal malformation. While from 
the last mentioned period to birth, is the period 
that develops fetal disease. 

The anomaly depends upon the stage at which 
the process of development ceased. If there was 
but an auricle, ventricle and aortic bulb, a heart 
with but a single auricle and ventricle results; or, 
the septum between the auricle and ventricle may 
be absent, giving the reptilian heart. The arrest 
of development may be in the inter ventricular 
septum, or between the auricle, when a patent 
foramen ovale results; which is the most common 
of all malformations of the heart. Any malforma- 
tion in the aortic bulb may lead to a double aorta. 

Infectious diseases and acute rheumatism cause 
fetal endocarditis and valvular changes similar to 
those found later in life. 

Pathology: — Many of these malformations render 
life impossible. Of all the malformations, a rever- 
sion of all the organs is the simplest met with. 
Ectopic cordis is seen at times; when, either from 
absence of the sternum or other causes, the heart 
is exposed externally. The changes found in the 



CONGENITAL HEART DISEASE. 203 

valves are confined to the right side of the heart, 
and are sclerotic in nature. The pulmonary orifice 
is more frequently diseased than the auriclo-ven- 
tricular. 

Symptoms : — At times there is a complete ab- 
sence of all symptoms that would call attention to 
any such lesion. The one marked symptom of con- 
genital heart disease is cyanosis. This usually ap- 
pears during the first week of life, and varies from a 
general duskiness to a violet or almost black hue. 
It is most marked about the lips, nostrils, lobules of 
the ear, the ringers and toes. During quiet, the 
color may nearly pass away, but returns on the 
slightest exertion. The fingers are clubbed and the 
nails are thickened and arched. The extremities are 
cold and the temperature subnormal. Dyspnea is 
present on exertion, and cough is present much of 
the time. There is a tendency to hemorrhages. 
The patient is sensitive to cold or slight changes 
in the temperature. There is a lack of develop- 
ment, both physically and mentally. 

Inspection: — An arching of the precordial re- 
gion is noticed in many of these cases, due to en- 
largement of the heart, while the bones are still 
pliable. 

Palpation : — This may reveal a thrill which is 
most pronounced at the base of the heart and to 
the left of the sternum. 

Percussion : — In the young the cardiac dullness 
is increased to the right. 

Auscultation: — This depends on the form of 
lesion present, but a systolic murmur at the pulmo- 
nary orifice is the one most frequently heard. 



204 CONGENITAL HEART DISEASE. 

Physical examination: — Should easily detect a 
transposition of the organs. 

Diagnosis: — This depends upon the presence of 
cyanosis, which begins during the first week of 
life, the right side of the heart being affected. 
The murmur is loud, musical, and has but a 
limited area of transmission. The bodily develop- 
ment is deficient and the mental state of the 
patient is below par. 

Prognosis : — This is not good. Many die with- 
in the first few days; fully one-half within the 
first year, and not more than one-fourth live to be 
four years of age, and the remaining fourth is 
still lessened before puberty. Those who live past 
the first week are subject to phthisis and hemop- 
tysis. 

Treatment: — If possible, these patients should 
live in a warm, dry climate. When this is not 
possible, the body must be protected by flannels 
and care taken that exposures be as light as pos- 
sible. The diet should be easily digested but 
liberal, and extra carbo-hydrates should enter into 
it. Gentle daily exercise, sponging of the body, 
with friction, and everything possible to assist the 
circulation should be observed. 



SYNCOPE. 205 



SYNCOPE. 

Fainting, swooning. 

This is a complete loss of consciousness which 
is usually temporary, but it may be a mode of 
death. 

Etiology: — It may result from cerebral or car- 
diac causes; acute diseases of the heart, as myo- 
carditis and pericarditis, or cardiac degeneration; 
imperfect blood supply; deficient nervous or mus- 
cular power, emotional disturbances, insufficient 
food, heat and close rooms, violent and protracted 
pain, amenorrhea and profuse natural discharges. 

Symptoms: — There is dimness of the sight, 
noises in the ears, the lips and face become pale 
and are covered with a cold perspiration, the 
pulse becomes weak, the breathing slower, and 
the patient falls. While in a few cases the patient 
may know what is done, yet in most of the cases 
he is not conscious; as recovery takes place there 
are deep sighs with confused ideas, vertigo and 
headache, and there may be vomiting and purging. 

Diagnosis: — This is usually easy but it should 
not be mistaken for hysteria. 

Prognosis: — When these attacks co-exist with 
heart disease it is an unfavorable sign, but usually 
the prognosis is favorable. 

Treatment: — The patient should be placed in a 
horizontal position at once, all tight clothing 
loosened, a current of air allowed to pass on the 
face; use fans and sprinkle cold water upon the 
face. During the attack ammon. carb., camphor 
or moschus may be used by olefaction. 



206 SYNCOPE. 



China: — When the fainting- results from a pro- 
fuse loss of blood, diarrhea, perspiration or from 
exercise. 

Digitalis: — When there is feebleness of the 
heart. 

Iodium: — This remedy should be studied when 
as a result of a constitutional debility, there is a 
tendency to faint. 

Opium: — When fainting is the result of fright. 

Linaria vulgaris: — The patient faints dead away 
without apparent cause, usually of cardiac origin. 



CHAPTER XXIX. 

EXOPHTHALMIC GOITRE. 

Basedow's disease, Grave's disease, Tachycardia 
strumosa. 

The true origin of this disease is still in doubt, 
but is usually ascribed to a derangement of the 
nervous system; or to an increased and perverted 
function of the thyroid gland. 

Etiology: — Its prevalence in certain families 
would lead one to believe that heredity is at 
least a predisposing factor, as well as a neurotic 
predisposition. It is more common in women than 
in men. And while seen at the extremes of life, 
it is a disease of the adult. Of the exciting 
causes are, profound mental impression, sudden 
fright, grief and mental anxiety. 

Pathology : — It should be remembered that the 
protrusion of the eye balls is not as marked after 
death as it appeared during life. The protrusion 
is due to an increased vascularity, and an excess 
of the retro-orbital fat. The thyroid is of a 
brownish color, is firm and uniformly enlarged; 
the enlargement being due to an increased vascu- 
larity and augmentation of the secreting structures. 
The heart may be normal or it may show both 
hypertrophy and dilatation. 

Symptoms : — The cardinal symptoms are an in- 
creased frequency of action and palpitation of the 
heart, protrusion of the eye balls, enlargement of 
the thyroid gland and tremor. On examination 
the cardiac impulse is seen to be forcible, while 
later in the affection, the superficial area may be 



208 EXOPHTHALMIC GOITRE. 

enlarged. The arteries, and at times the veins 
and capillaries, show pulsation. 

Palpation: — This shows an increase in the force 
of the cardiac impulse. 

Percussion: — Outlines an increased area of 
cardiac dullness as hypertrophy and dilatation of 
the heart take place. 

Auscultation: — Reveals an accentuation of the 
valvular sounds, and a blowing murmur over the 
heart and great vessels. The thyroid enlargement 
is due to dilatation of the blood vessels, especially 
in the arteries; it may be general or partial, and 
varies in size according to the condition of the 
the circulation. 

Pulsation of the gland is visible at times; a 
distinct thrill is felt over it and a double systolic 
murmur may be heard, but this is not constant. 

The exophthalmos varies in degree from time 
to time, dependent upon the amount of blood or 
lymph in the orbit; in advanced cases the promi- 
nence is more constant, due to an increase in 
the amount of adipose tissue. When the eye is 
turned downward the upper lid is seen to lag 
behind, not following properly the eyeball down- 
ward, and on closing the eyes a rim of white is 
seen above and below the cornea. 

Muscular tremor is an early symptom. It is 
fine in character, involuntary, and about eight to 
the second. There is great depression of spirits 
and even mania or melancholia may be present. 
The temperature may be elevated and associated 
with perspiration. 

Pigmentation of the skin is seen at times; an 






EXOPHTHALMIC GOITRE. 20Q 

edema appears, first about the ankles and then 
becomes general. The patient becomes weak and 
anemic; vomiting and purging is severe at times, 
while hemorrhages and albuminuria are often met 
with as compensation fails. 

Diagnosis: — This is dependent on the tachy- 
cardia, the tremor of the fingers, the exophthalmos 
and the enlargement of the thyroid. In many 
cases these symptoms do not all appear at first, 
and some one of the group may not appear at all. 

Prognosis : — Many of these cases are amenable 
to treatment. The disease may last for years and 
relapses are common. 

Treatment : — The surroundings of the patient 
should be as congenial as possible. A change of 
climate to a moderate elevation (3,000 ft.) is 
often beneficial. A wet pack and massage have 
assisted a few cases. Cold applications over the 
heart often assist in controlling the heart hurry. 
Rest in bed for several weeks is often beneficial. 
Surgical interference is often of service. The 
continuous galvanic current, applied from ten to 
twenty minutes, twice daily for three or four 
months, is often of service. Systematic respira- 
tory exercises that increase the chest expansion 
will be found beneficial in many of these cases. 

Lycopus Virginicus: — This remedy is probably 
indicated more frequently than any other. When 
there is a rapid pulse, abnormal cardiac action it 
being tumultuous and forcible. There is cough 
and often hemoptysis. It appears to give the 
best results when given in five-drop doses of the 
tincture every three hours. 



2IO EXOPHTHALMIC GOITRE. 

Spigelia anthel: — This remedy produces a vio- 
lent action of the heart, with great rapidity, pro- 
trusion of the eyeballs, and many symptoms that 
show a similarity to this disease. 

Ferrum iod. : — This remedy will be indicated in 
cases of disturbance of the female sexual organs, 
when the menses are scanty or suppressed. The 
body is emaciated and anemia present. It has 
cured exophthalmic goitre following suppression of 
the menses. 

Belladonna: — When indicated in this disease, it 
is usually early; when there is throbbing of the 
carotids and a beating is felt in the head. The 
pupils are dilated and the eyes are prominent. 
The thyroid is enlarged. The heart's action is 
forcible and increased in frequency. 

Natrum mur. : — When this remedy is indicated 
there is depression of the vital forces and the 
general nutrition of the patient is below normal. 
The mental condition present is one of hopeless- 
ness and fear regarding the future. The mouth is 
dry, the tongue is sore and mapped. The bowels 
are constipated, the stools so hard that they 
lacerate the mucous membrane of the sphincter. 
The skin is dirty and flaccid. Chlorotic symptoms 
are present. Coldness is complained of, that may 
be general or local ( lower half of the body). 
There is marked fluttering of the heart, with 
intermittent and irregular pulse. 

Iodium: — When this remedy is indicated there 
is marked emaciation and ravenous hunger which 
cannot be satisfied. There is protrusion of the 
eyeballs; with violent palpitation of the heart, 
worse on exertion; and a constant, heavy, oppres- 






EXOPHTHALMIC GOITRE. 211 

sive pain in the region of the heart. The pulse 
is rapid, small, weak, and often irregular. All 
diseases demanding this remedy are characterized 
by torpidity. 

Aurum: — Mental depression with suicidal ten- 
dencies are present when this remedy is indicated, 
Violent palpitation of the heart, with precordial 
oppression and hypertrophy of the heart. 



CHAPTER XXX. 
THE SENILE HEART. 

Definition: — This is a term applied to certain 
changes that result in a premature senility of the 
heart when it is compared with the other organs 
of the body. 

Etiology: — Of the many causes of the senile 
heart none are more potent than the great mental 
strain incident to modern business life. Senile 
vascular changes and peripheral resistance, all 
result in extra strain upon the myocardium and 
aid in its early degeneration. The condition just 
mentioned may be dependent upon structural 
changes in the arteries and capillaries or an in- 
creased amount of blood. Acute diseases at times, 
have such a profound influence upon the heart that 
it does not regain its vitality; not only acute, but 
chronic diseases as well, start a train of influences 
that render the heart indirectly incompetent. Loss 
of blood or fluids from the body and sexual excess, 
all act upon the heart in an injurious manner. An 
excess of food, stimulants and narcotics, as well 
as over-exertion and violent emotions, all tend to 
a premature senility of the heart. 

Pathology : — This is as varied as the etiology, 
but whether it is the myocardium or the arteries 
that present the greater structural changes, the 
primary lesion is nearly always in the inhibitory 
nerves. And while fatty degeneration, pigmenta- 
tion and aneurysm may be found, none of them 
are constant, but there is a weakened condition of 






THE SENTLE HEART. 213 

the myocardium with a greater or less degree of 
dilatation of the cavities. 

Symptoms: — Many of these cases steal upon 
their victims unawares. One of the earliest symp- 
toms complained of, is an uneasiness in the cardiac 
region which seldom amounts to an actual pain, 
but at times it does; it is always confined to the 
area of the heart and there are no shooting or 
darting pains connected with it. As the result of 
reflex causes or exertion, attacks of palpitation 
appear in which the heart's action is not forcible 
but rapid. These attacks are prone to appear at 
night, the result of gastric irritation. Tremor 
cordis appears at times without apparent cause. 
The pulse may be temporarily or permanently 
irregular, this may be both in force and frequency. 
If not controlled, sooner or later dilatation of the 
left ventricle follows. The intermission of the 
pulse is not to be looked upon with suspicion in 
the young, but it is in the aged, as it favors 
dilatation. The ease with which an irregularity is 
evoked should be observed, as it indicates the 
actual strength and relation of the heart and nerve 
supply. 

As stated before, the senile heart is nearly 
always dilated; the degree of the dilatation should 
always be noted. The position of the apex beat 
is to the left of the normal. The heart sounds 
undergo a gradual change. During the early 
stage the cardiac impulse is feeble, the first 
sound is altered and varying in character, being 
at times prolonged, blunt or feeble; again it is 
booming and clear; the second sound is accentu- 
ated, showing that the aorta is still dilatable. 



214 THE SENILE HEART. 

There soon appears a systolic murmur which may 
not be constant at first; it is heard first in the 
auricular area in the second intercostal space to 
the left of the sternum. It is dependent upon the 
left auricular appendix pressing- upon the chest 
wall, as a result of a dilatation of the heart, and 
the appearance of a mitral regurgitation, The 
murmur is more pronounced after exercise and 
may be absent after a rest; but sooner or later it 
is constant and is followed by a systolic tricuspid 
murmur. In a proportion of these cases there are 
changes in the aortic valve. A most constant 
symptom in many of these cases is breathlessness, 
especially during any exercise, but it may be 
present at any time and is spoken of as cardiac 
asthma, and is often a forerunner of heart failure. 
In many of these cases there are indications of 
gout or lithemia as indicated by the dyspepsia, 
glycosuria and condition of the kidneys and 
arteries. 

Diagnosis: — This is based upon all the given 
symptoms of a given case and the fact that the 
heart is showing senility before the other organs. 

Prognosis: — If taken in time, the habits and 
life of the patient may be so regulated that the 
life is prolonged; but the changes that produce 
the senile heart are progressive, unless controlled. 

Treatment : — These senile changes are degener- 
ative in character and while they may be stayed 
and the injury partially compensated for, if any- 
thing permanent is to be accomplished the patient's 
every habit must be carefully weighed and his 
whole life, physical, social and mental, carefully 
studied. It should be remembered that all affec- 



THE SENILE HEART. 2 1 5 

tions of the aged are not senile in character or 
origin. As the earliest symptoms appear, there is 
uneasiness and cardiac irritability with a slight 
degree of pain and "tremor cordis." The attend- 
ant should recognize that he is dealing with a case 
in which the metabolism is imperfect, and so far 
as is possible, the cause sought out and corrected. 

The pulse should be studied carefully. If the 
tension is low, inquiry must be made as to any 
continuous drain upon the system; an examination 
of the blood is of service in determining the 
actual condition. These same remarks hold true 
in cases where the pulse tension is high. After 
thoroughly investigating the conditions of the 
patient and removing all exciting causes, attention 
must be directed to the hygiene, exercise, diet 
and medicine. The hygienic surroundings of the 
patient should be perfect. The amount of exer- 
cise taken should be ascertained; for if it be in 
excess, it will lead to hypertrophy; but if rightly 
employed, it will strengthen the weak heart. The 
exercise as suggested by Oertel or the baths and 
exercises as carried out at Nauheim is often of 
great service. 

When the compensation is just full and the 
least exertion produces dyspnea, it is rest and diet 
that are demanded, not exercise. At times it will 
be found that during exercise the cardiac intermis- 
sions and irregularities disappear; when they do, 
they are reflex in their origin, and as the result of 
a more perfect metabolism, the urea is manufac- 
tured in an increased quantity and the blood 
purified. When breathlessness, palpitation and ir- 



2l6 THE SENILE HEART. 

regularity of the heart are provoked by exercise, 
it is rest that is indicated. 

In investigating the habits of the patient, the 
excessive use of food and drink should be inquired 
into, for many are over-eating. Those who are 
above the average weight, and as a result, are 
suffering from breathlessness, require such a diet 
as will reduce the obesity but at the same time, 
not in any way interfere with the myocardium. 
In those cases where there is dilatation of the 
heart and edema is appearing, showing involve- 
ment of the myocardium, the patient requires 
a dry diet. In those cases where the patient is 
below normal in weight and there is no dilatation, 
but there are intermissions, they require a nutri- 
tious diet. In giving directions for feeding these 
patients, the day should be so divided that there 
are five hours between each meal; the meals 
should be about equal in quantity, the stomach 
not being distressed by it; and no food should be 
taken into the stomach while it is still digesting. 
The stomach should have at least one hour after 
having finished the digestion of a meal, to rest 
before the next meal is partaken of. 

Five hours between meals — no solid foods in 
the meantime — the important meal at midday and 
dry food for those with dilated hearts, are rules 
to which there are no exceptions for invalids with 
diseased hearts. In all cases it must be ascer- 
tained what the patient can digest with the least 
distress when gout or lithemia is a prominent 
symptom. 

In selecting the diet for these patients only 
those meats with the finer and shorter fibres should 



THE SENILE HEART. 217 

be selected, and those vegetables that produce but 
little flatulence chosen. The meal should always 
be as dry as possible. If the food cannot be 
taken without fluid, not more than four or five 
ounces should be allowed with each meal. Tea 
and coffee, if taken at all, should be in modera- 
tion; alcohol is not beneficial to the heart, as its 
secondary action is depressing; a few sips of hot 
water will have a more permanent effect upon the 
heart than alcohol in any form; cocoa is too much 
of a food to take the place of a fluid and should 
be considered rather as a food. When thirst is 
complained of, the patient may be allowed to take 
eight ounces of hot water at four hours after each 
meal, this will clear the stomach and after a short 
rest will prepare it for the next meal. When there 
is a general anasarca the patient should be given 
the driest diet that it is possible for him to take, 
and not too much of that. Narcotics in any form 
are injurious to a weak heart; this remark applies 
to tobacco. 

Digitalis: — It is evident that in restoring a 
broken down myocardium, we have no remedy so 
frequently indicated as this one. The heart is 
weakened, it is unable to contract forcibly, and as 
a result the arteries are empty while the veins are 
distended, the heart's action is feeble and becomes 
irregular on any exertion. There is frequently a 
sensation as though the heart would stop if he 
moved; on sitting up the patient complains of 
faintness and anxiety. The pulse is slow much 
of the time but may become rapid. 

Nux vomica: — Or at times strychnia will be 
found serviceable in many of these cases. Its 



2l8 THE SENILE HEART. 

special indications are too well known to every 
physician to be repeated here. It will be found to 
benefit when the digestion is poor and the nervous 
system below par, hyperesthesia of all the senses 
being noted. It is one of the most active heart 
tonics and will restore the drooping vitality of 
many of these senile hearts. 

Arsenicum :— This remedy is frequently indicated 
by the stomach symptoms present, the nausea and 
distress that is so characteristic of it. The patient 
is apt to be subject to anginal attacks that appear 
frequently at night. It renders the heart more 
competent to perform its task and the patient can 
move about better after having taken it for a time. 

Arsenicum iod.: — This combination will act bet- 
ter than the arsenic alone, especially if there is 
marked change in the arteries combined with the 
other symptoms. A combination of arsenicum and 
strychnine is frequently of more service than either 
of these remedies alone. 

Strophanthus: — While this remedy is not as 

frequently indicated as digitalis, if there is any 

reason why digitalis cannot be taken, this remedy 
should be studied. 

Ferrum: — May be demanded in certain anemic 
cases. Glonoine is called for when anginal pains 
are frequent and the pulse of a high tension. 

Colchicum: — Where there is a history of gout 
with the symptoms calling for it. 

Lycopodium: — Where there is great flatulence 
and the other symptoms correspond. 



DROPSY. 219 



DROPSY. 

This is but an exaggerated physiological condi- 
tion. Normally, there is a continual pouring out 
into the tissue from the capillaries of a part of their 
contents, known as lymph. When once poured out, 
a part of it goes to nourish the tissue, while the 
remainder is taken up by the veins and lymphatics 
and restored to the circulation. During health it is 
removed as fast as it is poured out, and no accumu- 
lation takes place in the tissue. When there is an 
accumulation it constitutes dropsy. 

This is a common complication of certain forms 
of heart disease, when it is either the result of an 
obstruction to the return flow of venous blood, a 
loss of tone in the blood vessels, or a watery con- 
dition of the blood. Mitral insufficiency is the valv- 
ular lesion above all others that gives rise to 
dropsy; mitral stenosis is not as potent a factor in 
its production. Primarily, neither aortic insufficiency 
nor obstruction are attended with dropsy; but later, 
when the blood is pressed back into the left ven- 
tricle, it then appears. Dilatation of the heart is 
frequently accompanied by dropsy, while it is 
seldom found in cases of fatty degeneration, as in 
the latter, the force in the arterial circulation is 
lacking, and this force is essential to produce the 
pressure in the capillaries, that effusion may result. 

It should be remembered that in cardiac dropsy 
there is an increased fullness and pressure in the 
veins, and a reverse condition in the arteries; while 
in dropsy due to renal disease, the fullness and 
pressure is in the arteries. Cardiac dropsy is prob- 
ably due to a diminished absorption; while renal 

15 



220 DROPSY. 



dropsy, apart from cardiac involvement, is due to 
an increased exudation. 

While the treatment of dropsy is invariably the 
treatment of the condition that produced it, yet a 
few remarks here may be in order. The posture 
of the patient should receive attention. The hori- 
zontal position is demanded as it lessens the venous 
pressure in the limbs and relieves the heart. In 
cases where the dropsy is so marked that the 
patient cannot lie down, puncture and drainage of 
the legs is followed by relief. 

The diet should be as dry as possible. Of the 
remedies that may be called for are, apoc3'num 
can., stigmata maidis. digitalis, arsenicum, caffeine, 
and Crataegus oxyacantha. 



CHAPTER XXXI. 
ACUTE AORTITIS. 

Definition: — This is an acute inflammatory pro- 
cess involving the aorta. 

Etiology: — It is a rare affection and may occur 
during the course of any of the acute infectious dis- 
eases, or it may be a primary lesion apart from any 
acute, general disease. The acute diseases with 
which it has been related are, rheumatism, scarlet 
fever, measles, small-pox, and influenza; in some 
cases it has been associated with pregnancy, renal 
disease, syphilis and gout. It may arise independ- 
ently of any general disease, but in these cases 
there is a history of a chronic disease. 

Pathology: — The aorta is nearly always en- 
larged, presenting a fusiform or globular appear- 
ance. The inner surface is rough and uneven in 
appearance, there are patches which are soft in 
consistency and reddish or pink in color. Under 
the microscope the endothelium of the patches is 
seen to be swollen and infiltrated with leucocytes 
and flat, enlongated cells due to a proliferation 
of the connective tissue elements. The inflam- 
mation of the middle and outer coats is not as 
marked. 

Symptoms: — Many times the symptoms are lost 
sight of as the result of the primary disease. The 
most frequent symptom is a sensation of tightness 
in the chest, that may pass into a permanent burn- 
ing pain and simulate angina pectoris; but it has 
not the periods of complete remission that charac- 
terizes the true angina. These attacks may occur 



2 22 ACUTE AORTITIS. 



at any time, during rest or exercise, and are of 
short or long duration. During the attack, the 
face becomes pale and wears an expression of 
intense anxiety, the skin is cold and clammy, the 
pulse is rapid, and the mental condition is one of 
anxiety. The feeling of uneasiness between the 
attacks has been described as a sensation of burn- 
ing in the location of the aorta. The temperature 
is but little, if any, above the normal. The pre- 
cordia gives no indication of the trouble within, 
apart from a displacement of the apex beat out- 
ward and downward. 

Palpation: — Shows the cardiac impulse to be 
prolonged and increased in intensity. 

Percussion : — May show an increased aortic and 
cardiac dullness. 

Auscultation: — -May reveal nothing apart from 
an accentuation of the second aortic sound. Fre- 
quently the first sound is accompanied by a systolic 
murmur, and later a diastolic murmur may be de- 
veloped. 

Diagnosis: — This is based upon the location of 
the pain and the symptoms indicating disease of the 
aorta. The intermissions of the pain in angina 
pectoris should differentiate it from aortitis. 

Prognosis: — This is unfavorable; being abso- 
lutely hopeless in primary acute aortitis. 

Treatment : — Absolute rest, with a light nutri- 
tious diet should be prescribed. Ice bags, or Lett- 
er's tubes at times are of service to relieve the 
pain. During the anginal attacks, the nitrate of 
amyl or nitro glycerine are of some service, but not 
to the same extent as in cases of angina pectoris 



CHRONIC AORTITIS. 223 



due to fatty degeneration. The remedies are such 
as the general conditions demand. 

CHRONIC AORTITIS. 

This is a part of the general arterial sclerosis 
that affects the whole arterial system. 

Etiology: — This is essentially a disease of ad- 
vanced life. Heredity appears to be an important 
factor in its development in certain families, as they 
show degeneration of the arteries early in life. It 
is more common among men than women, and in 
those whose work demands prolonged physical strain. 
It is frequently associated with renal disease, gout, 
alcoholism and syphilis. 

Pathology : — The lesions ma) 7 be confined to the 
aorta, but more frequently they are but a part of a 
general disease of the arteries. In the earl) 7 stages 
of its development there appear patches, which are 
grayish and gelatinous in appearance, becoming 
yellow and doughy in time, with a tendency to the 
deposit of lime salt. These patches have a tend- 
ency to erosion, and as a result to form ulcers. 
The atheromatous changes are very apt to be about 
the orifices of the various arterial branches. The 
middle and outer coats show that they are invaded 
by newly formed cells, and are vascularized and 
thickened. These changes render the aorta subject 
to aneurysm and the ulcers may give rise to em- 
bolism. 

Symptoms: — The degenerative process usually 
extends beyond the aorta and may be observed in 
the brachial and temporal arteries, where it is indi- 
cated by the thickened, tortuous and rigid condition 
of the arteries, which appear like cords under the 



224 CHRONIC AORTITIS. 



palpating finger. The aorta is dilated at times to 
such an extent that pulsations may be felt in the 
second and third intercostal spaces to the right of 
the sternum, or dullness on percussion may be 
elicited. But more dependence is to be placed in 
auscultation in diagnosing dilatation of the aorta. 
The second aortic sound being low pitched, clang- 
ing or booming in character and appears prolonged. 
The aortic orifice may be dilated, giving rise to 
incompetency. A systolic murmur may be heard, 
due to thickening and roughening of the valves or 
calcareous deposits about the orifice. The patient 
often complains of uneasiness, weight or constriction 
with palpitation, breathlessness and paroxysms of 
cardiac asthma. Often there is a sub-sternal pain 
that extends out along the arteries, and also the 
sensation that the heart is going to stop. 

An examination of the arteries shows the tem- 
poral to be rigid and tortuous, while those of the 
extremities are as twisted cords under the finger. 
The carotid and subclavian arteries pulsate exces- 
sively and the aorta is seen to give a well marked 
pulsation in the jugular fossa. The radial pulse has 
a feeling of fullness and tortuosity and is of a 
high tension. The pulse wave is not large but is 
sustained and dies away slowly. The apex beat is 
farther to the left than normal and there is the 
heaving, sustained impulse indicative of cardiac 
hypertrophy. 

On auscultation there is an accentuation of the 
second aortic sound which is musical in character. 
If the case is of long standing there is usually 
some edema about the dependent parts. Aneurysm 
often develops as a result of the atheroma. 



CHRONIC AORTITIS. 225 



Diagnosis: — This is usually easy, except in 
those cases where it is local or latent. 

Prognosis: — When once established it never 
disappears. The disease may be retarded and if 
taken in time, may be held in check and life 
be rendered comfortable. 

Treatment : — This is the management of a case 
of arterial sclerosis. These patients should abstain 
from the use of alcohol in all forms. Their diet 
should be non-stimulating and contain little meat, 
but plenty of pure, soft water should be drank, but 
no water containing lime. They should have at 
least seven hours sleep each night, and if possible 
one hour after the mid-day meal. The skin should 
be kept in a healthy condition by a daily, warm, 
sponge bath. The bowels should be regulated by 
the food and exercise. All violent exercise should 
be avoided. 

Arsenic iodide: — While this remedy has not re- 
ceived a proving that has developed its whole 
action, yet from clinical observation, it stands with- 
out a peer in the number of these cases in which 
it is indicated, and benefits. It is indicated in the 
vertigo that accompanies many of these cases. The 
heart is enlarged, its action is irregular and in- 
creased. The pulse has a shotty feeling under the 
finger, and there are slight anginal pains at times. 
In many of these cases the kidneys are involved, 
giving rise to chronic interstitial nephritis. The 
patient is chilly; he cannot endure cold weather, 
and his family history reveals a tendency to pulmo- 
nary tuberculosis. This remedy will control the 
degeneration and restore the vitality. 



2 26 CHRONIC AORTITIS. 



Plumbum: — When this remedy is indicated there 
is melancholy, gloom, anxiety or mental torpor. 
The bowels are obstinately constipated, the stool is 
in the form of balls; the abdomen has a hard feel- 
ing; the muscles are knotted and the navel and 
anus violently retracted. There is violent spas- 
modic palpitation of the heart with anxiety and 
difficult breathing. The pulse is slow, small and 
contracted, but it may be rapid. 

Iodium: — This remedy produces a sensation as if 
the heart was squeezed, and of goneness or weak- 
ness of the chest. The pulse is accelerated by every 
exertion. There is degeneration of the arteries, ex- 
treme emaciation with great hunger. The patient 
has dark hair and eyes and cannot endure warmth. 

Lithium iodide: — This remedy is indicated when 
in connection with the arterial degeneration, there 
is a history of rheumatism with soreness in the 
region of the heart. There is trembling and flutter- 
ing of the heart, the distress extending up between the 
shoulders and even to the head, where it is felt as 
a painful throbbing. This remedy is serviceable 
where there is the lithic acid diathesis with chronic 
nephritis. 

Gold and sodium chloride: — This remedy is in- 
dicated in those cases where there is a syphilitic 
basis, or the patient is suffering from the effects of 
sexual abuses. Melancholy is present with a desire 
for death, the tongue is red and glazed. There is 
nervous dyspepsia, taking food increases the pain in 
the stomach and causes an evacuation of the bowels. 

Strontium iodide: — This remedy is indicated 
where there is catarrhal asthma, chronic bronchitis, 



CHRONIC AORTITIS. 227 

or various pulmonary troubles. In order to receive 
the desired effect it must be used in doses of from 
rive to ten grains. 

Potassium or sodium iodide: — Have both been 
extensively used and abused in treatment of this 
condition. They will be found of service when the 
patient is very irritable, melancholy, with intellectual 
weakness. He is subject to syphilitic and mercurial 
headaches; and the syphilitic affections of the bones 
and periosteum; especially if he has been mercu- 
rialized. 

Sabal serrulata ( saw palmetto ) : — While there 
has not appeared in the meagre proving, anything 
to indicate that this remedy is of service in this 
disease, yet in my clinic, I have frequently seen its 
beneficial effects when given to old men suffering 
from sub-acute and chronic prostatitis, with difficult 
urination, and malnutrition with great emaciation. 



CHAPTER XXXII. 

ANEURYSM OF THE AORTA. 

Definition: — An aneurysm is a pulsating tumor 
due to a dilatation of an artery, with the interior 
of which it is connected. 

Etiology: — This is a disease of middle life, and 
seen most frequently among men whose work de- 
mands prolonged physical strain. The uric acid 
diathesis, rheumatism, syphilis and alcohol play an 
important part in the production of arterio-sclerosis 
and thus in aneurysm. In this connection obliterat- 
ing endarteritis of the vasa vasorum should be men- 
tioned. Increased blood pressure is among the 
exciting causes in the thoracic aorta, and trauma- 
tism in the abdominal aorta. 

Pathology: — The existence of atheroma in every 
case of aneurysm of the aorta leaves no doubt of 
the association of the two processes. During the 
early stages both the inner and middle coats are 
thickened; while later, each is atrophied to such an 
extent that the outer coat practically forms the 
covering of the aneurysm. In cases of rupture it is 
the inner coat that ruptures first, then the middle* 
and later the outer covering ruptures. A fusiform 
aneur}'sm is a general dilatation of the aorta and 
is seen most frequently in the ascending and trans- 
verse portion of the arch. A saculated aneurysm 
is due to the giving way of a circumscribed por- 
tion of the arterial wall and may vary in size from 
a pea to that of a man's head. Within the aneurys- 
mal sac the blood may be partially fluid, with old 
and new thrombi, the color and consistency of the 



ANEURYSM OF THE AORTA. 229 

latter varying with age. The recent formations are 
soft, while later they become firmer or calcified, 
and of a yellow color. Occasionally, either by 
obliteration of the sac from deposits of blood within, 
or from closure of the orifice leading to it, a cure 
is completed. Of the aneurysms of the aorta, three- 
fourths are confined to the thoracic portion and 
one-fourth to the abdominal. Of those developing 
from the thoracic aorta, 60 per cent, are confined 
to the ascending portion, 30 per cent, to the trans- 
verse and 10 per cent, to the descending portion. 

Symptoms: — Aneurysm, if small, may produce 
no symptoms. But when they become large, they 
then give rise to pain, palpitation and breathless- 
ness. Anginal attacks are common, with pain radi- 
ating to one or both shoulders and arms, accom- 
panied at times with fluttering and throbbing of 
the heart. 

Inspection: — There is apt to be the pallor so 
frequently seen with disease of the aorta, and a 
pulsation at a point where it is not normally 
present; this is the most positive sign of aneurysm. 
It must be determined that the pulsation is not due 
to the heart or great blood vessels being in either 
an exposed or an abnormal position. The apex 
beat may be displaced according to the site and 
size of the aneurysm. If there is a bulging of the 
chest wall, it may be localized or diffused. 

Palpation: — The apex beat may indicate hyper- 
trophy of the heart, but not necessarily. On plac- 
ing the hand on such a tumor, a pulsation is de- 
tected, which is expansile in character, and in some 
cases, is accompanied by a distinct thrill. By very 



230 ANEURYSM OF THE AORTA. 

careful examination it may be determined that the 
pulsation of the tumor follows that of the apex 
beat. 

Percussion : — Will outline the heart and show 
any change in its position or size, and also show a 
dullness, the result of aneurysm. 

Auscultation: — Reveals a low pitched second 
sound, which if well marked, is loud and ringing 
and coincident with the diastolic shock. 

The Pulse: — An aneurysm gives rise to a char- 
acteristic difference between the two radial pulses. 
The one affected is delayed, diminished in height, 
its duration is longer and subsidence more gradual 
than normal. 

The digestive system may be affected by pres- 
sure upon the esophagus and difficulty in swallowing 
results. Pressure upon the stomach does not pro- 
duce any marked symptoms, owing to the movable 
character of the abdominal viscera. Pressure upon 
the thoracic duct may interfere with the blood 
forming apparatus and emaciation result. Pressure 
upon the trachea, bronchi or lung will interfere with 
respiration and breathlessness, dyspnea, cough or 
hemoptysis result. 

Trachial tugging is observed when the head is 
bent backward and the tissues on the anterior sur- 
face of the neck put on a tension; if the fingers 
are now placed between the cricoid and thyroid 
cartilages it will be found that the trachea is pulled 
downward with every cardiac contraction. This 
sign, while not pathognomonic of aneurysm, is often 
present when the transverse portion of the arch is 
involved. 



ANEURYSM OF THE AORTA. 23 1 

Deglutition may be difficult, due to pressure 
upon tne esophagus. In some cases- a localized per- 
spiration is noticed, as well as areas of increased 
cutaneous temperature. The nervous system pre- 
sents a variety of symptoms described as weight, 
tightness, soreness and pain; and paralysis of the 
laryngeal muscles, from pressure upon the vagus or 
recurrent laryngeal nerve is met with. The left 
vocal cord is the one most frequently affected, as 
that recurrent laryngeal nerve winds about the 
transverse portion of the arch of the aorta. If the 
right sub-clavian artery is involved, a similar con- 
dition may be met with on the right side. 

Unilateral paralysis of the diaphragm may result 
from pressure on the phrenic nerve. Changes in 
the size of the pupils from pressure upon the s}'m- 
pathetic nerves are common occurrences. The 
sternum and ribs in front, and the spine and ribs 
behind, may undergo erosion and necrosis from 
pressure. When the aneurysm is confined to the 
ascending portion of the arch of the aorta, it gives 
rise to a pulsating tumor in the second and third 
intercostal space, to the right of the sternum. In 
those cases where the sac develops upon the pos- 
terior surface, the pulsations are not present. The 
apex beat is usually to the left and downward from 
the normal point. Palpation over the region of the 
sac gives two impulses, the first may be a thrill. 

Percussion outlines an increased area of dullness, 
while auscultation reveals, usually, a systolic murmur 
followed by a short sound. The aneurysm may 
press upon the superior vena cava or right sub-cla- 
vian, and edema of the right side of the face and 
arm result. If the tumor is very large it may in- 



2 32 ANEURYSM OF THE AORTA. 

terfere with the infereior vena cava and edema of 
the lower extremities result. Pain is a constant 
symptom and is dull and aching in character; 
should the aneurysm press upon a bone, it is boring, 
if upon a nerve trunk, it is neuralgic in character. 
The pain may be severe in the right arm and the 
muscles become atrophied. Aphonia is present at 
times, due to the implication of the right recurrent 
laryngeal nerve. Cough, d}'spnea and breathlessness 
appear if there is much pressure upon the corres- 
ponding lung. When it is the transverse portion of 
the arch that is involved, the symptoms are more 
intense than in that just mentioned. This is due to 
the narrow antero-posterior diameter and as a result, 
greater pressure upon the structure by the aneurysm. 
Posteriorly there is the trachea and esophagus, 
which, when pressed upon, gives rise to cough, 
dyspnea and dysphagia. If the bronchi be pressed 
upon, bronchorrhea and dyspnea result. The recur- 
rent laryngeal nerve on the left side may be impli- 
cated and aphonia result. If the aneurysm extends 
upward it may effect the sympathetic nerves, caus. 
ing dilatation of the pupil if there is simple irrita- 
tion, or contraction, if there is paralysis. It may 
press upon the thoracic duct and induce emaciation. 
Should it extend forward it will press upon the 
manubrium which becomes eroded and necrosed. 

Aneurysm of the descending aorta, if close to 
the diaphragm, gives rise to a diffused pulsation 
which is accompanied by a thrill that is easily de- 
termined. Percussion shows the extent of the 
aneurysm; while auscultation usually shows a single 
sound or late systolic murmur. There is apt to be 
difficulty in swallowing, and dyspnea due to pres- 



ANEURYSM OF THE AORTA. 233 

sure on the left lung; if the pressure is marked 
there may be a bloody expectoration, increased 
vocal fremitus, comparative dullness, bronchial breath- 
ing and other signs indicative of consolidation. 

Aneurysm of the abdominal aorta is accessible 
to physical examination, and as a result, it is not so 
difficult to make out the symptoms. The pulsat- 
ing tumor may be seen and felt. Auscultation will 
reveal a systolic murmur. The digestive function 
may be interfered with as well as the intestines. 
If it should press upon the liver, icterus is often 
present. 

Diagnosis: — The recognition of an aneurysm 
connected with the thoracic aorta is often difficult. 
The diagnosis must be based upon the symptoms as 
already enumerated. The presence of arterioscle- 
rosis in an individual from thirty to forty-five years 
•of age; whose occupation demands prolonged mus- 
cular strain; when taken in connection with those 
symptoms that result from pressure upon different 
structures, as pain, dyspnea, aphonia, cough with 
bronchorrhea, edema and physical signs of a pulsat- 
ing tumor; the increased area of cardiac dullness; a 
systolic murmur with a systolic and diastolic shock, 
are sufficient to pronounce it a case of aneurysm. 
Tracheal tugging may be noticed, but it is a symp- 
tom of secondary importance, as it is present with 
other conditions. The diagnosis is especially diffi- 
cult when the aneurysm is small, where there are 
no symptoms apart from those of pressure, and in 
those cases where the symptoms are not constant. 

Differential Diagnosis : — Mediastinal tumors 
produce all of the pressure symptoms of an 



234 ANEURYSM OF THE AORTA. 

aneurysm, but they are not apt to produce the 
bulging or pulsation found in aneurysm. When 
they do produce pulsation, it is quicker and not so 
heaving and steady as in aneurysm, and they do 
not possess the systolic and diastolic shock of 
aneurysm, nor is the heart necessarily affected. 
Mediastinal abscess gives the history of fever and 
evidence of septicemia. 

Pulsating empyema is situated on the left side 
at the base of the lung, extends over a large 
superficial area and there is no murmur or double 
shock as in aneurysm. The pulse and pressure 
symptoms of aneurysm are wanting. In pulmonary 
tuberculosis the fever and emaciation are more pro- 
nounced, the bacillus tuberculosis are present in the 
sputum, and the cardiac-vascular symptoms indicat- 
ing aneurysm are absent. It should be remembered 
that cases of hypertrophy of the pancreas may com- 
press the abdominal aorta and give rise to a mur- 
mur heard in the line of the aorta, below the 
point of compression. It also gives rise to pain in 
the region of the stomach, felt immediately after 
eating; there are also pains due to pressure upon 
nerve roots, that may give rise to the sensation of 
a girdle. A pulsation is noticed in the region of 
the stomach, due to the action of the aorta upon 
the enlarged pancreas. 

Prognosis: — This is never good, but depends 
upon the situation of the aneurysm, the direction 
in which it extends, its shape, and whether it is 
extending slowly or rapidly. Aneurysms of the 
intra-pericardial portion of the aorta are especially 
dangerous. There is but little to support the aorta 
at this point and it has a greater degree of move- 



ANEURYSM OF THE AORTA. 235 

ment than in other parts; as a result, rupture of 
the aneurysm takes place early. In those situated 
above the attachment of the pericardium the prog- 
nosis is better, especially in those that extend for- 
ward. It is not so good in those extending back- 
ward on account of the possible pressure upon the 
root of the lung, vena cava or pneumogastric nerve. 
When the transverse portion of the arch is involved 
there is the danger from rupture, also from pressure 
upon important structures, and asphyxia and pul- 
monary collapse result. If the aneurysm extends 
forward there is not so much danger. 

Sacculated aneurysms, while they develop rapidly 
and may prove fatal, the mouth of the sac does 
not develop so rapidly, as a result the current of 
blood is slower within the sac and a deposit of 
fibrin may take place. The development of the 
aneurysm is thus checked and a cure may result. 
In the fusiform variety, while the development is 
slower its shape does not permit of a deposit of fibrin 
and as a result there is no tendency to repair. 

Treatment : — This is not satisfactory. The ob- 
ject is to render the blood pressure as low as pos- 
sible, to slow the circulation and render it equable. 
In order to accomplish this, absolute rest in bed for 
at least two months is imperative. If the use of 
the bed pan causes much straining it may be advis- 
able to have the patient use a commode, but he 
should not be allowed to sit up for anything else. 
The rest should not only be physical but mental. 

Careful attention should be devoted to the diet. 
The liquids should be reduced as far as possible, 
not more than forty ounces being taken in twenty- 
four hours. The amount of food taken at each 



236 ANEURYSM OF THE AORTA. 

meal should be about the same, that there may be 
no excessive repletion and depletion, and as a re- 
sult, no marked change of circulation. The food 
taken should be concentrated, at least not bulky, 
like potatoes. The object being the reduction of 
the volume of blood, that the pressure within the 
aneurysmal sac may be lessened and the blood 
fibrin readily deposited. Constipation must be 
avoided as its effects are very injurious to these 
patients. Insomnia at times is very annoying and 
will tax the physician's therapeutical resources. 
When as the result of the pressure, pain is severe, 
venesection will be found to afford an immediate 
relief by lowering the blood pressure within the 
aneurysm, and allowing a deposit of fibrin. The 
introduction of a coil of wire into the sac or the 
employment of the pole of a galvanic battery is 
attended with danger of embolism. The iodide of 
potassium has been used with a degree of success 
in increasing doses of from twenty to forty grains 
three times a day; just how its beneficial effects 
are produced is difficult to say, but probably it is 
by depressing the action of the heart, promoting 
diuresis and inspissation of the blood. 

Veratrum vir. : — This drug has the power of 
reducing the pulse rate when given in five-drop 
doses of the tincture every three hours. 

Gallic acid: — In one half drachm doses, three 
times a day, has cured in a few cases. 

Ergot: — This has been used with a degree of 
success in aneurysm. When used it has been in- 
jected around the tumor. 

Aconite, digitalis, gelsemium, laurocerasus, have 



ANEURYSM OF THE AORTA. 237 

often been of service, but must be used in full 
doses. 

Compression has benefited many cases, an ac- 
count of its use may be found in any surgery. 

Baryta muriatica: — This remedy and the other 
preparations of baryta are reported to have cured 
cases of aneurysm. In their proving they have 
developed palpitation, dyspnea, oppression with 
irregular and forcible action of the heart. 

When the pain cannot be relieved by other 
remedies, five grains of lactucarium at night, will 
often give a good night's rest with but little, if 
any, bad after effects. 

RUPTURE OF THE AORTA. 

While this condition is not common, yet it has 
been observed from time to time where there was 
no aneurysm; but there was usually a degenerated 
condition of the wall of the aorta. 



CHAPTER XXXIII. 
ACUTE ARTERITIS. 

Definition: — This is an acute inflammation of 
the wall of an artery. 

Etiology: — It is most frequently the result of 
some infective process as pyemia, ulcerative endo- 
carditis and enteric fever, and in arteries that 
traverse an area of suppurative inflammation. 

Pathology : — When the infection extends from 
without, the outer and then the middle coats are 
infiltrated with round cells. This process may ex- 
tend through all three of the coverings and leads 
to perforation of the wall of the vessel and hemor- 
rhage. The inner coat, not having any indepen- 
dent blood vessels, is involved indirectly by an 
emigration of leucocytes that infiltrate it. When 
the infection starts from within as the result of a 
softening thrombus or an infective embolism, there 
is a necrotic destruction of the inner coat, which 
is followed by an infiltration of the middle and 
outer coats with round cells. The acute produc- 
tive form of arteritis is usually the result of acute 
tissue changes surrounding the arteries, that lead 
to over-growth of connective tissue. 

Symptoms : — Acute arteritis may occur during 
an acute primary lesion or during convalesence. 
The most pronounced symptom is a localized pain 
in the affected region which is worse from motion 
and pressure. The artery appears as a cord under 
the finger, is tender to the touch, the pulse is 
obliterated and there is coldness of the skin, and 



ARTERIOSCLEROSIS. 239 



swelling. The temperature of the part is lowered 
and gangrene may follow. 

Diagnosis: — This is often difficult to make; 
but tenderness along the course of the artery; a 
hard cord-like feeling under the finger when the 
vessel is pressed upon; at times, obliteration of 
the artery; disappearance of the pulse and the 
appearance of gangrene in the part which the 
artery supplies; all point to this as the disease. 

Prognosis: — This is grave; but if the process 
can be controlled and the infection stopped, it is 
not so grave. 

Treatment: — This consists in the management 
of the primary lesion. 

ARTERIO-SCLEROSIS. 

Definition : — This is a hyaline degeneration of 
the structures composing the walls of the arteries, 
with hyperplasia and a substitution of connective 
for muscular tissue; and as a result, associated 
with contraction and induration of the artery. 

Etioiogy : — This being a senile, degenerative 
change, age, together with sex, syphilis, alcohol, 
gout and rheumatism are most fruitful causes. It 
has been observed that the middle and inner coat of 
an artery increases in thickness with advancing 
years. This last statement must be taken with a 
degree of latitude, for cases will be found in which 
the arteries are as hard in one at forty as in an- 
other at sixty-five. The subject of its appearance 
depends much upon hereditary tendencies and 
whether the life of the individual has been one of 
self-denial or self-indulgence. Cases are met with 



24O ARTERIOSCLEROSIS. 



in which there are no indications of sclerosis, but 
they are the exception, as in nearly all cases 
there is a degree of degeneration in some of the 
arteries, if not in all. At times these arterial 
changes will be noticed in the young, when it is 
usually associated with a low grade of mental 
development. 

Males suffer from this disease more than 
females, from the fact that a greater number of 
the former are addicted to the use of alcohol, 
suffer from syphilis, gout, rheumatism, and their 
work demands a more prolonged physical strain. 
Alcohol produces these results in different ways, 
it accelerates the heart's action by disturbing the 
digestive function of both the stomach and the 
liver; and if in excess, it so poisons the blood 
that it acts as an irritant. 

Syphilis is an important factor in the etiology 
as is borne out in the reports of military life. Its 
effects may be circumscribed or diffused. Rheu- 
matism has been so frequently observed in those 
suffering with this disease, that it is recognized as 
one of the causes. Gout, diabetes, and lead 
poisoning have been the exciting causes. Of the 
acute infectious diseases that act as causes are 
diphtheria, scarlet fever, influenza, malaria and 
typhoid fever. Over-feeding and drinking give 
rise to the conditions that favor its development 
when associated with a sedentary life. Hard work 
by subjecting the heart to strain and hypertrophy, 
leads to an increased tension in the blood vessels 
and thus becomes a cause. 

Pathology : — This process may be diffused, em- 
bracing nearly all of the arterial system, or it may 



ARTERIOSCLEROSIS. 24I 

be circumscribed. When the latter condition pre- 
vails, nodular elevations are to be seen upon the 
inner lining of the vessel. These vary in size 
from a pin point to that of a small coin; they are 
raised a little above the surface; early, they are of 
a translucent, grayish color, and are covered with 
a smooth, unaltered endothelium. Later, these no- 
dules undergo degenerative changes, which may 
be, either a hardening due to infiltration with cal- 
careous material, which renders them of a light 
color; or the focus may soften and a necrotic 
atheromatous ulcer result; calcareous changes may 
then follow. 

These areas of degeneration may be few in 
number and separated from each other, or they 
may be continuous. When diffused, they are 
most frequent in the small vessels and in elderly 
subjects. In the diffused form the process is found 
distributed through the arterial system, with the 
nodular form involving the aorta and larger ves- 
sels. In this diffused form the inner coat of the 
artery is much thickened and there is an extensive 
proliferation of the sub-endothelial connective tis- 
sue, together with a hyaline degeneration of the 
middle coat of the larger vessels. In the later 
stages, the muscular and elastic tissue may have 
disappeared altogether and a calcareous deposit 
may take place, giving the wall of the vessel a 
rigid feeling. Atheromatous abscesses appear, 
especially in the aged, and by rupturing, give rise 
to ulcers. 

Owing to a lack of nutrition from a narrowing 
of the vessels, atrophy of the heart, kidney or 
liver may result; but hypertrophy of the heart is 



242 ATRERIO-SCLEROS1S. 

more commonly met with. When the coronary 
arteries are involved the myocardium is liable to 
suffer; undergoing a fibrous degeneration and all 
the cusps may become sclerotic. The pulmonary 
arteries show the same changes and with the other 
vessels may show aneurysms, due to a weakened 
condition. Owing to the increased resistance to 
the blood current, the arterial tension is increased 
and the part taken by the vessels in propelling 
the blood is lost, with cardiac hypertrophy as a 
result. 

Symptoms; — The external signs are never a 
guide by which to judge of the extent of arterio- 
sclerosis, as cases have been frequently met with at 
autopsies, in which there was calcareous degenera- 
tion of the aorta and yet the vessels of the extrem- 
ities gave no indications of it; while in other cases 
the vessels showed the hardness and felt like bone; 
an examination showed their serpentine course and 
elongation. In those cases where the aorta is 
involved and a degree of contraction takes place, 
the body as a whole, or the part supplied by any 
artery that is much involved, will show a progres- 
sive emaciation. As the arterial tension increases, 
as it will sooner or later, hypertrophy of the 
heart ensues. This is indicated by the increased 
cardiac impulse, the displacement of the apex beat 
to the left and downward, the increased diameter 
of the heart and the accentuation of the second 
aortic sound. 

When the aorta is markedly involved in the 
process and as a result elongated; at times, it will 
be noticed that the apex beat is within the nipple 
line while the patient is sitting up, but that it 



ARTERIOSCLEROSIS. 243 

passes outward as far as the axillary line when 
the patient lies upon the left side. In cases where 
the vessels leading from the heart are atheroma- 
tous as well as the cardiac valves, the sounds of 
the heart are propagated very distinctly along 
these atheromatous arteries to a great distance. 
The second aortic sound is accentuated; this is 
dependent upon the dilatation of the aorta and the 
increased tension within it. As the aorta is di- 
lated, the aortic ring is also soon dilated, and 
aortic incompetency follows. 

When the coronary arteries are involved, palpi- 
tation of the heart occurs after meals, with dysp- 
nea upon the slightest exertion, so that patients 
have to stop walking or promenading. Cases have 
been observed in which patients have died, sup- 
posedly due to this disease, during the act of 
coitus. In cases of mitral stenosis, sclerosis of the 
pulmonary artery has frequently been observed, 
producing a chronic stasis of the lung. In the 
the kidney this disease gives rise to a gradual 
atrophy and sign of cirrhosis. When it involves 
the arteries of the brain it appears at first in an 
indefinite way; the individual is conscious that he 
does not perform his mental work as easily as 
formerly, and it is observed that it is not of as 
high an order; it requires some will force to 
enable him to do his usual labor and, while the 
mind may remain clear and vigorous, there are 
attacks of melancholia, hypochondria and irrita- 
bility. 

As the process advances insomnia appears, the 
mental condition weakens, there is vertigo, and in 
time, softening of the brain appears. A miliary 



244 ARTERIOSCLEROSIS. 



aneurysm may rupture at any time, giving rise to 
apoplexy and hemiplegia. In the extremities the 
symptoms depend upon the stage of the disease, 
but are indicated by coldness or cyanosis and ulti- 
mately gangrene. 

Diagnosis: — When the changes wrought by 
this disease can be observed or felt, the diagnosis 
becomes easy; but where they are only presump- 
tive or impossible to make out; an increased 
arterial tension, a hardening of the arteries to the 
feel, an accentuation of the second aortic sound 
and a hypertrophy of the left ventricle of the 
heart, form a characteristic group of symptoms. 
The increased arterial tension is usually one of the 
first evidences of the changes that are taking 
place; with this, dyspnea soon appears, with pal- 
pitation of the heart, coldness of the extremities 
and marked headaches. In many cases a differ- 
ence is noticed in the radial pulses, due to a dis- 
ease of one of the arteries. When the thoracic 
aorta is most involved there are attacks of angina 
pectoris or distress in the cardiac region, with the 
pains radiating to the left shoulder and arm, with 
difficulty in breathing. When the peripheral 
arteries are affected, there are sensations of numb- 
ness, formication, paresthesia and cramps present. 
It is not easy to recognize the arterio-sclerotic 
shrunken kidney, but a large amount of clear 
urine, with low specific gravity, little albumen, and 
indications of stasis, with hypertrophy of the 
heart, should lead to this as the probable cause. 
Senile gangrene frequently shows this as the cause. 
The patient is pale, thin, yellow and shows the 
arcus senilis early. 



ARTERIO-SCLEROSIS. 245 

Prognosis: — This varies according to the seat 
of the lesion and the extent of the changes. 
When any one of the important organs of the 
body shows unmistakable signs of the disease, the 
prognosis becomes more unfavorable. Although 
one may live for a long time with marked degen- 
eration, the disease is a chronic one, is progres- 
sive and may terminate life suddenly, as in cases 
of apoplexy or rupture of the aorta, or it may be 
a very slow form of death. The statement that 
"a man is as old as his arteries" is ever true. 

Treatment : — There is no disease that demands 
of the physician a more thorough investigation of 
every phase of the patient's life than does this one; 
and there is no disease in which the patient must 
more thoroughly observe every hygienic law and 
physiological condition, that he may stop its inroads 
upon his vitality. All the conditions that interfere 
with the nutrition of the body must be avoided. 
Every habit should be inquired into carefully and 
if found to be other than is conducive to a normal 
condition, it should be corrected. 

The diet should be investigated, a meat diet, 
especially the red meat, should hot be used, beef 
tea, meat extracts and preparations of that class 
should be used sparingly, if at all. Fish may 
be used occasionally, but in moderation. The 
diet should be non-stimulating. Milk, especially 
skimmed milk, is excellent in those cases where 
the kidneys are involved and there is a tendency 
to gout and rheumatism. The only objection to a 
milk diet is in those cases where there is a calca- 
reous infiltration, as the lime in the milk favors 
this condition. Water should be taken in abund- 



246 ARTERIOSCLEROSIS. 

ance, both pure and soda water. Liquors in all 
forms should be avoided; if this is found to be 
impossible, all sweet wines, champagnes and bur- 
gundies should be eliminated, and only the lighter 
wines used. 

The bowels should be thoroughly evacuated at 
least once each day. The skin must be kept in a 
hygienic condition. If obesity is present it should 
be reduced and avoided in the future. Excitement 
and bodily effort are dangerous; many cases of 
sudden death during coitus are attributed to this 
as the cause. The patient should cultivate a 
cheerful disposition, as irritation wears upon the 
heart and then upon the arteries. The patient 
must not be indolent but should have a degree of 
exercise, not violent, and something to keep the 
mind active and engaged. They should retire 
early and rise early. 

The reader is referred to the following reme- 
dies which were considered under the subject of 
Chronic Aortitis: Arsenic iodide, plumbum iodide. 
Lithium iodide, gold and sodium chloride, stron- 
tium iodide, iodides of potassium and sodium, 
sabal serrulata. ' While this group contains the 
remedies most frequently indicated, the following 
may be necessary at times: 

Cuprum sulph. 2x: — In syphilitic cases, where 
many of the symptoms calling for cuprum are pres- 
ent. It should be given night and morning for a 
long period. 

Plumbum iodide, 3X: — When interstitial nephri- 
tis is present, with constipation and colicky pains. 

Zinc phosphide: — Presents many of the symp- 
toms of cerebral vertigo and should be compared 
with arsenic iodide in this condition. 



ARTERIAL DEGENERATION. 247 

Colchicine: — Where there is a history of gout 
and chronic rheumatism this preparation will be 
found more reliable than colchium, when the 
symptoms of the latter are present. 

Glonoine: — This remedy will give temporary 
relief in reducing- the extreme vascular tension. 
Patients soon become used to its action and as a 
result it should be a last resort. Drop doses of the 
first centesimal (i. e. one per cent.) solution is used. 

When gangrene appears, lachesis, secale and 
arsenicum should be studied. 

For the treatment of the various divisions of 
this disease, the reader is referred to works on the 
particular organ involved. As it is usually well 
advanced before the physician is consulted, the 
best that can be expected is to stay the process 
and compensate in part for the injury done. 

ARTERIAL DEGENERATION. 

Fatty degeneration: — This is most frequently 
met with in those who are past the meridian of 
life; but it may be met with in chlorotic girls. 

While any of the coats of the arteries may be 
affected, it is most frequently seen in the inner 
coat, where it forms a part of the atheromatous 
process. When it occurs as an independent lesion 
it most frequently results from toxic agents in the 
blood, and as the result of disturbances of the 
circulation. The microscope may reveal small, 
yellow or white spots, or streaks in the endo- 
thelium; the endothelial cells may be granular or 
filled with oil drops. In severe cases there may 
be erosion of the endothelial surface, and the mus- 



248 ARTERIAL INFILTRATION. 

cular elements of the middle coat may show fatty 
degeneration. This form of degeneration may 
lead to a rupture of the blood vessel or to a cal- 
careous infiltration. 

Hyaline degeneration: — This is seen involving 
the inner coat of the smaller arteries, where it is 
often but the first evidence of a beginning degen- 
eration. It is frequently the result of infectious 
fevers or intoxication, when the small arteries 
suffer most. 

ARTERIAL INFILTRATION. 

Calcareous Infiltration: — This is one of the ter- 
minations of the atheromatous changes; but a 
complete calcification of the artery may occur 
apart from any previous degeneration. This infil- 
tration may occur as a result of a thrombus be- 
coming organized, or where there is some bone 
disease present that results in destruction of the 
bone and a loading of the blood with lime salts. 

Amyloid Infiltration: — This results from syph- 
ilis, tuberculosis, chronic lead poisoning or sup- 
puration, especially that of a bone. The smaller 
and medium sized arteries are the ones most 
affected by infiltration which leads to weakening 
of the arterial walls and aneurysm. This form of 
infiltration is frequently found in other organs of 
the body. 

THE CORONARY ARTERIES. 

The coronary arteries are subject to the same 
diseases as the other arteries of the body, as 
atheroma, fatty and calcareous degenerations; 



THE CORONARY ARTERIES. 249 

aneurysm, etc. As these arteries are filled by the 
recoil of the aorta, it is evident that any disease 
of the latter or of the aortic orifice will interfere 
with their nutrition. There are no positive symp- 
toms by which these changes can be detected dur- 
ing life. 



NDEX. 



Aconite, in 

angina pectoris . 

aneurysm of the aorta . 

cardiac hypertrophy . 

endocarditis, acute. 

chronic, 

myocarditis 

palpitation . 

pericarditis . 
Actinomycosis . ' . 
Adonis vernalis, in 

cardiac hypertrophy 

chronic endocarditis . 
Agaricine, in 

cardiac dilatation 

fatty degeneration 
Alcoholic beverages, in 

aortic incompetency . 

aortitis, chronic 

arrhythmia . 

arterio-sclerosis . 240, 

bradycardia 

dilatation, chronic cardiac 

endocarditis 

fatty accumulation 

fatty degeneration 102, 

hypertrophy, cardiac 

mj^ocarditis . . 74, 

senile heart 

weak heart 
Amnion, valer. , in tachycardia 
Ammonia, aromatic spirits of, 
in 

fatty accumulation 

myocarditis 

thrombosis . 
Ammonium bromide, in fatty 

accumulation 
Ammonium carbonate, in syn- 
cope 

Amyl nitrate, in 

acute aortitis . 

angina pectoris . 

fatty degeneration 
Amyloid disease 

infiltration 
Anemia, in general therapeu- 
tics 

Aneurysm of the aorta, 

abdominal aorta 

ascending aorta . 

change in size of pupils 

cough .... 

17 





Aneurysm of the aorta — 


Cont'd. 


196 


definition 


. 228 


236 


descending aorta 


232 


94 


diagnosis 


233 


123 


differential diagnosis 


233 


138 


etiology 


. 228 


74 


fusiform 


228 


179 


pain 


. 232 


55 


pathology 


. 228 


71 


physical signs 


229 




prognosis 


. 234 


94 


sacculated . 


228 


138 


symptoms 


. 229 




treatment 


235 


89 


Aneurysm of the heart 




105 


definition 


112 




diagnosis 


. 112 


147 


etiology 


112 


225 


pathology 


. 112 


177 


prognosis 


113 


246 


symptoms 


. 112 


183 


treatment 


113 


87 


Aneurysm of the valves 


. 174 


132 


Angina Pectoris, 




99 


definition 


. 188 


105 


diagnosis 


190 


93 


etiology . 


. 188 


, 76 


pathology 


188 


217 


symptoms — tru 


3 and 


200 


pseudo 


189 


187 


treatment 


. 191 


Antimon. arsen. in 






weak heart 


. 201 


100 


Antimon. crud. in fatty 


iegen- 


74 


eration . 


105 


174 


Aorta, rupture of the . 
Aortic incompetency 


. 237 


101 


definition 


143 




diagnosis 


. 146 


205 


etiology 


143 


pathology 


. 143 


222 

192 
107 


physical signs 


146 


prognosis 


. 147 


symptoms . . , 


145 


treatment 


. 147 


119 


Aortic stenosis 




248 


definition 


149 




diagnosis 


. 151 


41 


etiology 


149 




pathology 


. 149 


233 


physical signs 


150 


231 


prognosis . ' 


. 153 


232 


symptoms 


150 


232 


treatment 


. 153 



252 


INDEX. 




Aortic stenosis and regurgita- 


Arsenicum, iod., in 




tion 




cardiac hypertrophy 


. 95 


etiology 


153 


endocarditis 


137 


prognosis 


. 154 


fatty degeneration . 


. 107 


symptoms . 


154 


myocarditis . 


79 


treatment 


. 154 


palpitation 


. 179 


Aortitis, acute. 




senile heart . 


218 


definition 


221 


Arteritis, acute. 




diagnosis 


. 222 


definition 


238 


etiology . - . 


221 


diagnosis . 


. 239 


pathology 


. 221 


etiology 


238 


physical signs 


222 


pathology 


. 238 


prognosis . 


. 222 


prognosis 


239 


symptoms 


221 


symptoms 


. 238 


treatment 


. 222 


treatment 


239 


Aortitis, chronic 




Arterial degeneration 


247 


definition 


223 


fatty degeneration . 


. 247 


diagnosis . 


. 225 


hyaline degeneration 


248 


etiology 


. 223 


Arterial infiltration 


. 248 


pathology 


. 223 


amyloid infiltration 


248 


physical signs 


224 


calcareous infiltration 


. 248 


prognosis 


. 225 


Arterial pulse. See pulse, 


ar- 


symptoms . 


223 


terial. 




treatment, 


. 225 


Arterio-sclerosis, 




Aphonia, in aneurysm 


of the 


definition 


. 239 


aorta 


232 


diagnosis 


244 


Apis mellifica, in 




etiology . 


. 239 


hydropericardium 


68 


pathology 


239 


Apocynum cann. in 




prognosis 


. 245 


dropsy 


. 220 


symptoms 


242 


hydropericardium 


67 


treatment 


. 245 


Arnica mont. in 




Asclepias cornuti, in brady- 


acute cardiac dilata 


tion 82 


cardia .... 


. 183 


cardiac hypertrophy 


T . 94 


Athletic feats, a cause of car- 


weak heart 


201 


diac dilatation 


80 


Arrhythmia. 




Atrophy of the heart 


. 114 


definition 


. 175 


Atropine, in fatty degenera- 


diagnosis, 


177 


tion .... 


. 109 


etiology . 


. 176 


Aurum, in exophthalmic 


prognosis 


177 


goitre .... 


. 211 


symptoms 


. 176 


Aurum mur., in 




treatment . 


177 


angina pectoris . 


194 


Arsenicum alb., in 




endocarditis, chronic 


. 137 


acute dilatation 


. 82 


myocarditis . 


79 


angina pectoris . 


193 


tachycardia 


. 187 


arterio-sclerosis 


. 247 


Aurum mur. natronatum, 


in 


cardiac hypertrophy 


r . 94 


aortitis 


226 


chronic endocarditi 


3 . 137 


arterio-sclerosis 


. 246 


dropsy . 


220 


Baryta carb. in 




endocarditis . 


. 124 


chronic endocarditis 


. 138 


fatty degeneration 


105, 106 


Baryta muriatica, in 




hydropericardium . 


. 67 


aneurysm of the aorta 


237 


malignant endocarc 


itis 127 


Basedow's disease (see exoph- 


myocarditis 


. 74 


thalmic goitre. ) 




palpitation . 


179 


Baths, Nauheim, in 


. 42 


pericarditis 


. 56 


cardiac dilatation 


87 


senile heart . 


218 


malignant endocarditis 127 


Arsenicum, iod., in 




myocarditis 


. 79 


aortitis . 


225 


Belladonna, in 




arterio-sclerosis 


. 246 


chronic endocarditis 


. 139 



INDEX. 



253 



Belladonna, in 

endocarditis 

exophthalmic goitre 

pericarditis 

thrombosis, cpa'diac 
Bicycling, a cause of 

cardiac dilatation . 
Bradycardia 

definition 

diagnosis 

etiology 

pathology 

prognosis 

symptoms 

treatment . 
Bryonia in 

endocarditis . 

pericarditis 
Cactus grand, in 

angina pectoris . 

cardiac hypertrophy 

chronic endocarditis 

endocarditis 

pericarditis 

tobacco heart 
Caffeine, in 

dropsy 

endocarditis . 

myocarditis 

thrombosis . 

weak heart 
Calcarea carb. in 

chronic endocarditis 

fatty accumulation 

palpitation 
Calcarea hypophos. in 

cardiac dilatation 
Calcarea phosph. in 

weak heart 
Calcareous degeneration 

infiltration 
Camphor, in syncope 
Cancer of the heart 
Cannabis Indica in 

bradycardia 
Cannabis sat. in palpitation 



124 

210 

58 

174 

80 

182 
183 
182 
182 
183 
182 
183 

124 
56 

193 
95 

134 
124 

58 
198 

220 
142 
79 
174 
201 

140 
101 
181 



200 
119 
248 
205 
113 

183 

180 



Cardiac emaciation or atrophy 114 
definition . . .114 
diagnosis . . . 115 

etiology . . . 114 

pathology . . .114 
symptoms . . . 115 

treatment . . .115 

Cardiac murmurs, in clinical 
examination ... 21 

Cardiac hypertrophy, see hyper- 
trophy, cardiac. 

Cardiac Pathology, general 34 

Chamomilla, in palpitation 181 



Cheyne-Stokes respiration, in 31 


bradycardia 


183 


fatty accumulation 


98 


fatty degeneration 103, 109 


myocarditis . 


78 


China, in 




palpitation 


180 


syncope 


206 


weak heart 


200 


Chronic aortitis, see aortitis, 


chronic 




Cimicifuga racemosa, in 




acute endocarditis 


123 


chronic endocarditis 


141 


pericarditis 


57 


Coffea, in palpitation 


180 


Colchicine, in arterio-sclerosis 247 


Colchicum, in 




pericarditis 


57 


senile heart 


218 


Cold applications, in 




dilatation 


81 


endocarditis 


123 


exophthalmic goitre 


209 


rupture of the heart . 


111 


Collinsonia, in cardiac hyp 


3r- 


trophy .... 


95 


Congenital heart disease, 




diagnosis 


204 


etiology 


202 


pathology 


202 


physical signs 


203 


prognosis 


204 


symptoms 


203 


treatment 


204 


Constipation, in 




aneurysm of the aorta 


236 


aortic incompetency . 


148 


aortitis, chronic 


225 


arterio-sclerosis . 


246 


fatty accumulation 


100 


general therapeutics . 


41 


Convallaria, in 




cardiac hypertrophy 


94 


acute cardiac dilatation 


82 


chronic dilatation . 


88 


endocarditis, chronic 


135 


endocarditis, acute 


124 


tobacco heart 


198 


Coronary arteries . 


248 


Corrigan's pulse, in 




aortic incompetency 


145 


clinical examination . 


29 


Cough, in general therapeu 


- 


tics of heart disease . 


32 


Crataegus oxyacantha, in 




cardiac dilatation . 


88 


cardiac hypertrophy . 


95 


dropsy 


220 


weak heart . 


201 



254 



INDEX. 



82. 



Crotalis hor. , in 

malignant endocarditis 

myocarditis 
Cuprum met., in 

angina pectoris . 

fatty degeneration 
Cuprum sulph., in arterio 

sclerosis .... 
Cysts, cardiac 

hydatid .... 
Deglutition, in aneurysm of 
the aorta . . 230, 
Delirium cordis, in arrhyth- 
mia 

Dicrotic pulse 
Diet, in 

aneurysm of the aorta 

angina pectoris 

aortic incompetency . 

aortitis, chronic 

arterio-sclerosis . 

congenital heart disease 

dilatation, cardiac . 

dropsy 

endocarditis, acute 
" chronic 

" malignant 

fatty accumulation 
' ' degeneration 

hydropericardium . 

hypertrophy 

myocarditis 

pericarditis, adherent 
' ' chronic 

senile heart . 

syphilis of the heart 

therapeutics, general 

weak heart 
Differential diagnosis, in 

aneurysm of the aorta 

dilatation of the heart 

pericarditis 

hypertrophy . 
Digitalis, in 

aneurysm of the aorta 

angina pectoris . 

bradycardia . 

cardiac hypertrophy 

cardiac syphilis 

dilatation 

chronic endocarditis 

dropsy . 

endocarditis . 

fatty accumulation 

fatty degeneration 

hydropericardium 

myocarditis 

palpitation . 

pericarditis 

senile heart 



128 
76 

194 
106 

246 
113 

71 

231 

175 
30 

236 

192 

147 

225 

245 

204 

87 

220 

122 

133 

127 

99 

105 

67 

93 

79 

63 

55 

216 

117 

40 

200 



233 

54 

54-55 

55 

236 
196 

184 

95 

117 

87 

133 

220 

124 

101 

108 

68 

79 

180 

56 

217 



Digitalis, in 

syncope ... 206 
weak heart . . . 201 
Dilatation of the heart, acute 

definition ... 80 
diagnosis ... 81 

differential diagnosis . 54 
etiology ... 80 

pathology ... 80 
physical signs . . 81 

prognosis ... 81 
symptoms . . .80 

treatment . . .81 
Dilatation of the heart, chronic, 
definition . . .82 

diagnosis ... 86 
etiology . . .82 

pathology ... 83 
physical signs . . 85 

prognosis ... 86 
symptoms . . .84 

treatment ... 87 
Dropsy, 

etiology . . . .219 
treatment . . . 220 
Dyspnea, in clinical examina- 
tion 31 

Echinacea, in malignant endo- 
carditis . . . .128 
Edema, in general therapeutics 41 
Empyema, in aneurysm of the 

aorta 234 

Endocarditis, simple, acute or 
verrucose, 
definition 
diagnosis 
etiology . 
pathology . 
prognosis 
symptoms 
treatment 
Endocarditis, chronic, 
diagnosis 
etiology 
pathology 
prognosis 
symptoms 
treatment . 
Endocarditis, malignant 
definition 
diagnosis 
etiology . 
pathology . 
physical signs 
prognosis 
symptoms 
treatment 
Epigastric pulsation, in clin- 
ical examination 



120 
122 
120 
121 
122 
121 
122 

131 

129 
129 
131 
131 
132 

125 
126 
125 
125 
126 
127 
126 
127 

17 





INDEX. 


255 


Ergot, in aneurysm of the 


Ferrum, in 




aorta .... 


236 


chronic endocarditis 


136 


Examination of patient 


15 


palpitation 


180 


apex beat 


15 


senile heart 


218 


auscultation . 


20 


Ferrum iod. in 




cardiac murmurs 


21 


exophthalmic goitre 


210 


inspection 


15 


Ferrum phos. in 




palpation 


17 


chronic endocarditis 


140 


percussion 


18 


fatty accumulation 


101 


Exercise, in 




Fetal disease, in 




aneurysm of the heart 


113 


congenital heart disease 


202 


angina pectoris 


191 


Fetal malformations, in 




aortic stenosis 


153 


congenital heart disease 


202 


aortitis, chronic 


225 


Fibroid endocarditis, see endo 




arterio-sclerosis . 


246 


carditis, chronic 




congenital heart disease 


204 


Fibromata .... 


113 


dilatation, cardiac 


87 


Fucus vesiculosis, in 




endocarditis, chronic 


132 


fatty accumulation 


100 


exophthalmic goitre . 


209 


Fusiform aneurysm 


228 


fatty accumulation 


100 


Galvanic current, in 




hypertrophy, cardiac . 


93 


exophthalmic goitre 


209 


myocarditis 


79 


Gallic acid, in 




senile heart . 


215 


aneurysm of the aorta 


236 


tachycardia 


186 


Gallop rhythm, in 




therapeutics, general . 


41 


arrhythmia 


176 


weak heart 


200 


Gelsemium, in 




Exercises, Oertel's method 


42 


aneurysm of the aorta 


236 


Schott's resistance . 


44 


fatty degeneration 106, 


107 


Exophthalmic goitre, 




Glonoine, in 




diagnosis 


209 


acute aortitis 


222 


etiology . 


207 


angina pectoris 


192 


pathology 


207 


arterio-sclerosis . 


247 


physical signs . 


208 


cardiac syphilis 


117 


prognosis 


209 


cardiac thrombosis 


174 


symptoms 


207 


fatty degeneration 


107 


treatment 


209 


senile heart 


218 


Fainting, see syncope. 




Goitre, see exophthalmic goitre. 


Fatty accumulation with ii 


l- 


Gold chloride, see aurum mur 




nitration 




Gold and sodium chloride, see 




definition 


97 


aurum mur. natr: 




diagnosis 


99 


Graphites, in fatty accumula 


t- 


etiology . 


97 


tion 


101 


pathology 


97 


Graves' disease — See exopb 


- 


physical signs 


98 


thalmic goitre. 




prognosis 


99 


Heart in its relation to the 


symptoms 


98 


chest walls, etc. 


13 


treatment 


99 


Heart tonics and stimulants, in 


Fatty degeneration. 




aneurysm of the heart . 


113 


definition 


101 


angina pectoris . 


192 


diagnosis 


104 


aortitis, acute 


222 


etiology 


101 


endocarditis 


142 


pathology . 


102 


fatty accumulation 


101 


physical signs 


103 


fatty degeneration 105 


,109 


prognosis 


104 


myocarditis, acute 


74 


symptoms 


103 


myocarditis, chronic . 


79 


treatment . 


105 


rupture of the heart 


112 


Fatty degeneration of the a 


r- 


syphilis of the heart . 


117 


teries 


247 


tachycardia 


187 


Fatty heart 


97 


thrombosis, cardiac 


174 


in cardiac pathology 


35 


wounds of the heart 


119 



256 



INDEX. 



Helleborus, in hydropericard- 

ium 69 

Helonias, in weak heart . 200 

Hemoptysis, in heart disease 32 

Hemopericardium, 

diagnosis ... 63 

pathology ... 63 

prognosis ... 64 

symptoms ... 63 

treatment ... 64 

Hiccough, in heart disease . 32 

Hyaline degeneration of the 

arteries .... 248 

Hydatid cysts . . . 71 

Hydrocyanic acid, in 

fatty degeneration . 106 

tobacco heart . . . 198 

Hydropericardium, 

definition . . .65 

diagnosis ... 67 

differential diagnosis . 54 

etiology . . . 65 

pathology ... 66 

prognosis ... 67 

symptoms ... 66 

treatment ... 67 

Hypertrophy, in 

cardiac pathology . 36 

Hypertrophy, cardiac 

diagnosis ... 92 

definition ... 90 

differential diagnosis . 55 

etiology ... 90 

pathology ... 90 

physical signs . . 91 

prognosis ... 92 

symptoms ... 91 
treatment . . .93 

Ignatia, in 

acute cardiac dilatation 82 

palpitation . . . 180 

tobacco heart . . 198 

weak heart . . . 201 

Insomnia, in aneurysm . 236 

Inspection, in 

clinical examination . 15 

Iodides, in 

aneurysm of the aorta 236 

arterio-sclerosis . 246 

chronic aortitis . . 226 

- chronic myocarditis . 79 

Iodine, in 

arterio-sclerosis . . 246 

chronic aortitis . . 226 

exophthalmic goitre . 210 

pericarditis . . 58 

syncope . . . 206 

Kali carb. in hydropericardium 68 

Kali ferrocyanatum, in 

aortitis ... 227 



Kali ferrocyanatum, in 

fatty degeneration 

hydropericardium 

pericarditis 

weak heart 
Kali iod. in 

arterio-sclerosis 

angina pectoris . 

aneurysm 
Kali muriaticum, in 

chronic endocarditis 
Kalmia latifolia, in 

cardiac hypertrophy 

chronic endocarditis 
Kidneys, in 

clinical examination 
Kissengen water, in 

fatty accumulation 
Kola, in weak heart 
Lachesis, in 

arteriosclerosis . . 247 

malignant endocarditis 127 

myocarditis ... 75 
Lactucarium, in aneurysm of 

the aorta . . . .237 
Laurocerasus, in 

acute cardiac dilatation 82 

aneurysm of the aorta . 236 

angina pectoris . . 194 
Lilium tigrinum, in angina 

pectoris .... 195 
Linaria vulgaris, in syncope 206 

Lipoma 113 

Liquors, see alcoholic bever- 



106 
68 
58 

201 

246 
193 
236 

140 

95 
136 

32 

100 
201 



Lithium carbonicum, in chron- 
ic endocarditis . . 139 

Lithium iodide, in 

aortitis . . . .226 
arterio-sclerosis . . 246 

Lycopodium, in 

fatty accumulation . 101 

hydropericardium . 69 

senile heart . . . 218 

Lycopus Virginicus, in 

cardiac hypertrophy . 95 

chronic endocarditis . 135 
exophthalmic goitre . 209 
fatty accumulation . 101 

Lymphomata . . . 113 

Magnesia phos., in pseudo 
angina .... 193 

Malformations, see congenital 
heart disease. 

Malignant endocarditis, see 
endocarditis, malignant. 

Massage, in 

angina pectoris . . 192 
exophthalmic goitre . 209 
fatty accumulation . 100 



INDEX. 



257 



Massage, in 

myocarditis 

weak heart 
Mediastino pericarditis, 

diagnosis 

etiology- 
pathology 

prognosis 

symptoms 

treatment . 
Mercurius, in 

chronic myocarditis 

hydropericardium 
Metallic ring, in clinical 

animation . 
Mitral incompetency, 

definition 

diagnosis 

etiology . 

pathology 

physical signs 

prognosis 

symptoms 

treatment . 
Mitral obstruction and regurg- 
itation, 

diagnosis 

etiology 

pathology 

physical signs 

prognosis . . * . 

symptoms 

treatment 
Mitral regurgitation, in clin- 
ical examination 
Mitral stenosis. 

definition 

diagnosis 

etiology 

pathology 

physical signs 

prognosis ... 

symptoms 

treatment 
Moschus, in syncope . 
Muriatic acid, in myocarditis 
Murmurs, cardiac, in clinical 

examination 
Myocarditis, acute, 

definition 

diagnosis 

pathology 

physical signs 

prognosis 

symptoms 

treatment 
Myocarditis, chronic 

definition 

diagnosis 

etiology 



79 
200 

60 
60 
60 
60 
60 
61 

79 
69 

21 

155 
156 
155 
155 
156 
157 
155 
157 



162 
160 
160 
161 
162 
161 
162 

22 

158 
160 
158 
158 
159 
160 
159 
160 
205 
75 

21 

72 
73 
72 
73 
73 
72 
74 

70 
78 
76 



Myocarditis, chronic — Continued. 

pathology ... 77 

physical signs . . 78 

prognosis . . . 78 

symptoms ... 77 

treatment ... 79 

Myomata .... 113 

Naja tripudians, in 

angina pectoris . . 196 

cardiac hypertrophy . 95 

chronic endocarditis . 134 

pericarditis ... 59 

Natrum iod., in 

angina pectoris . . 193 

arterio-sclerosis . . 246 

aortitis .... 227 

Natrum mur. , in 

chronic endocarditis . 141 

exophthalmic goitre . 210 

Nauheim baths ... 42 

in senile heart . . . 215 

Neoplasms of the pericardium, 

diagnosis .... 71 

pathology . . . 71 
prognosis . . . .71 

symptoms ... 71 

treatment ... 71 

New formations, of the heart 113 

of the pericardium . . 70 

Nicotine poisoning, 

physical examination . 197 

treatment . . . 197 

Nitrate of amyl, see amyl nitrate. 

Nitroglycerine, see glonoine. 

Nux Vomica, in 

angina pectoris . . 196 

chronic endocarditis . 138 
palpitation . . .179 

senile heart . . . 217 

tobacco heart . . 198 

weak heart . . 201 

Obesity, in 

arterio-sclerosis . . 246 

fatty accumulation . 99 

Oertel's treatment, in . 42 

fatty accumulation . 100 

senile heart , . 215 

Opium, in 

bradycardia . . .184 

palpitation . . 181 

syncope .... 206 

Oxygen, in 

cardiac thrombosis . 174 

fatty degeneration . 105 

syphilis of the heart . 117 

Pain, in clinical examination 33 

Palpation, in clinical examina- 
tion .... 17 

Palpitation, 

definition . . . 178 



258 



INDEX. 



Palpitation — Continued. 




etiology 


178 


physical signs 


. 178 


prognosis 


179 


symptoms 


. 178 


treatment . 


179 


Paracentesis, 




in hydropericardium 


. 67 


of the pericardium 


59 


Paralysis of the diaphragm, 


in 


aneurysm of the aorta 


. 231 


Paralysis, unilateral, in an- 


eurysm of the aorta 


. 231 


Paris quadrifolia, in brady- 


cardia 


. 184 


Patent foramen ovale, in 




congenital heart disease 


. 202 


reptilian heart 


202 


Pathology, general cardiac, 




acute, infectious diseases 34 


age in infectious diseases 34 


atrophy - 


. 36 


cause of circulatory dis- 


turbance . 


37 


degenerative changes 


. 35 


fatty heart . 


35 


hereditary diseases 


. 34 


hypertrophy 


37 


palpitation 


. 34 


reaction to irritation . 


36 


rheumatic diseases 


. 34 


Percussion, in clinical exam- 


ination 


18 


Pericardial syphilis, see syph- 


ilis, pericardial. 




Pericardial tuberculosis, see 


tuberculosis, pericardial. 




Pericarditis, acute, 




definition 


47 


etiology . 


47 


pathology 


47 


symptoms 


48 


treatment 


55 


Pericarditis, adherent, 




definiton 


61 


diagnosis 


62 


etiology . ... 


61 


pathology . 


61 


prognosis 


62 


symptoms 


62 


treatment 


62 


Pericarditis, chronic, 




diagnosis 


53 


differential diagnosis . 


54 


etiology . 


53 


prognosis . 


55 


treatment 


55 


Pericarditis, 
fibrous 


49 


hemorrhagic 


53 



Pericarditis — Continued. 

primary tubercular . 52 

purulent ... 52 

serous .... 51 

Phaseolus nana, in weak heart 201 

Phosphoric acid, in 

fatty degeneration . 105 

weak heart . . . 200 

Phosphorus, in 

fatty degeneration, 105, 107 
malignant endocarditis 128 
myocarditis ... 76 
weak heart . . . 200 

Phytolacca, in fatty accumula- 
tion , . . .101 

Platina, in palpitation . . 181 

Plumbum, in 

arterio-sclerosis . . 246 
chronic aortitis . . 226 
fatty degeneration . 105, 107 

Pneumopericardium, 

diagnosis .... 64 
etiology ... 64 

pathology ... 64 
physical signs . . 64 

prognosis .... 65 
symptoms ... 64 

treatment ... 65 

Pneumo-therapy, in cardiac 
syphilis .... 117 

Position, in clinical examina- 
tion 15 

Psorinum, in chronic myocar- 
ditis .... 79 

Pulmonary incompetence. 

definition . . . 163 

diagnosis . . . 164 
etiology .... 163 
pathology . . . 163 
physical signs . . .164 
prognosis . . . 164 
symptoms . . .163 
treatment . . . 165 

Pulmonary stenosis 

definition . . . 165 

diagnosis . . . 166 
etiology . . . 165 

pathology . . . 165 
physical signs . . 166 

prognosis . . . 166 
symptoms . . .166 
treatment . . . 166 

Pulsatilla, in palpitation . 180 

Pulse, in 

aneurysm of the aorta 230 

Pulse, in clinical examination 

arterial ... 25 

dicrotic .... 29 
inspection . . .25 

palpation ... 25 



INDEX. 



259 



Pulse, in clinical examination 

high tensioned 

low tensioned 
Pulsus alternans, in 

arrhythmia 
Pulsus bigeminus, in 

arrhythmia 
Pulsus paradoxicus, in 

arrhythmia 

adherent pericarditis 
Quinine, in myocarditis 
Reduplication, in 

clinical examination 
Relation of the heart to the 

chest wall 
Reproductive system, in 

clinical examination 
Residence, in therapeutics 
Respiratory system, in 

clinical examination 

aneurysm of the aorta 
Rest, in 

aneurysm of the aorta 

aneurysm of the heart 

angina pectoris 

aortic incompetency 

aortitis, acute 

atrophy of the heart 

dilatation . . 81, 8 

dropsy 

endocarditis, malignant 

exophthalmic goitre 

fatty degeneration 

hemopericardium 

hypertrophy . 

mitral incompetency 

myocarditis . . 74 

palpitation 

pericarditis 

rupture of the heart 

syphilis of the heart 

therapeutics, general 

thrombosis, cardiac 

wounds of the heart 
Rheumatic poison, effects of 
Rhus tox. in 

chronic endocarditis 
Rupture of the aorta 
Rupture of the heart, spontane- 
ous 

diagnosis . . . Ill 

etiology . . . .110 

pathology . . . 110 

prognosis . . .111 

symptoms . . . 110 

treatment . . .111 
Sabal serrulata, in 

arterio-sclerosis . . 246 

chronic aortitis . . 227 



28 
28 

175 
175 
175 

175 
62 

74 

21 

13 

33 

40 

31 
232 

235 

113 
191 
147 
222 
115 
7 

220 
127 
209 
105 

64 

94 
157 
, 79 
179 

55 
111 
117 

39 
173 
119 

34 

137 
237 



Sacculated aneurysm 


228 


Salicylic acid, in malignant 




endocarditis 


128 


Sanguinaria, in fatty degen- 




eration .... 


108 


Sargassum bacciferum, in 




fatty accumulation . 


100 


Saw palmetto, see sabal serru- 




lata. 




Scarifications, in therapeutics 


41 


Schott's exercise 


44 


in cardiac dilatation 


87 


in angina pectoris 


191 


in aneurysm of the heart 


113 


senile heart . 


215 


Secale, in 




aneurysm of the aorta 


236 


arterio-sclerosis 


247 


Senile heart, the, 




definition 


212 


diagnosis 


214 


etiology .... 


212 


pathology 


212 


prognosis .... 


214 


symptoms 


213 


treatment 


214 


Septic forms, in malignant 




endocarditis . 


126 


Silicates in weak heart . 


200 


Skin, in clinical examination. 


32 


Sleep, in therapeutics 


41 


Sparteine sulph., in 




cardiac hypertrophy 


95 


dilatation 


89 


fatty accumulation. 


101 


fatty degeneration 


108 


tachycardia 


187 


Sphygmograph, in clinical ex- 




amination .... 


26 


Spigelia, in 




angina pectoris 


194 


endocarditis 


123 


exophthalmic goitre 


210 


palpitation 


179 


pericarditis . 


57 


Spongia tost, in 




angina pectoris . 


193 


chronic endocarditis 


140 


Stigmata maidis, in 




' chronic endocarditis 


139 


dropsy 


220 


hydropericardium 


69 


Stimulants, alcoholic, see alco- 




holic beverages. 




Stimulants, cardiac, see hearl 




tonics. 




Strophanthus hisp. in 




cardiac dilatation 


88 


chronic endocarditis 


135 


senile heart 


218 



260 



INDEX. 



Strophanthus hisp. in 

syphilis of the heart 

thrombosis 
Strontium iodide, in 

aortitis .... 

arteriosclerosis 
Strychnia arsen., in myocar- 
ditis 

Strychnia, in 

cardiac thrombosis 

chronic endocarditis 

fatty accumulation . 

fatty degeneration 
Strychnia phos., in myocar- 
ditis 

Suggestion, in 

cardiac hypertrophy 

tachycardia . 
Sulphur, in 

chronic endocarditis 

hydropericardium 

myocarditis 

pericarditis . 

palpitation 

weak heart . 
Syncope, 

definition 

etiology 

diagnosis . 

prognosis 

symptoms 

treatment . 
Syphilis of the heart, 

diagnosis . 

etiology 

pathology 

prognosis 

symptoms 

treatment 
Syphilis, pericardial, 

diagnosis . 

prognosis 

symptoms 

treatment . 
Syphilinum, in chronic myo 
carditis .... 
Tabacum, in angina pectoris 
Tachycardia, 

definition 

diagnosis 

etiology . 

pathology 

symptoms 

prognosis 

treatment 
Tachycardia strumosa, see ex 

ophthalmic goitre. 
Temperature, change of 
Therapeutics, general 



117 

174 

226 
246 

79 

174 
141 
101 
108 

79 

94 

187 

139 

69 

79 

59 

181 

200 

205 
205 
205 
205 
205 
205 

116 
115 
116 
116 
116 
117 

70 
70 

70 
70 

79 
194 

185 
186 
185 
185 
185 
186 
186 



40 
39 



Thrombosis, cardiac 




definition 


. 172 


diagnosis . 


173 


etiology 


. 172 


pathology 


172 


prognosis 


. 173 


treatment 


173 



Thyroidine, in fatty accumula- 
tion 100 

Tobacco heart, see nicotine 
poisoning. 

Trachial tugging, in aneurysm 
of the aorta . . . 230 

Tremor cordis, in 

arrhythmia . . 176 

senile heart . . .213 

Tricuspid incompetency, 

definition . . .167 
diagnosis . . . 169 
etiology . . . 167 

pathology . . . 167 
physical signs . . 168 

prognosis . . . 169 
symptoms . . .168 
treatment . .. . 169 

Tricuspid stenosis, 

definition . . . 169 
diagnosis . . . 171 
etiology . . . . 169 
pathology . . . 169 
physical signs . .170 

prognosis . . . 171 
symptoms . . .170 
treatment . . . 171 

Tuberculosis of the heart . 113 

Tuberculosis, pericardial, 

diagnosis .... 69 
etiology ... 69 

prognosis .... 70 
symptoms ... 69 

treatment ... 70 

Typhoid form, in malignant 
endocarditis . . .125 

Vanadium, in fatty degenera- 
tion 108 

Veratrum alb. in 

angina pectoris . .194 
pericarditis . . 59 

tobacco heart . . 198 

Veratrum vir. in 

aneurysm of the aorta 236 
cardiac hypertrophy 95 

endocarditis . . 123 

fatty degeneration . 108 

pericarditis . . 58 

Verrucose endocarditis . 120 

Vichy water, in 

fatty accumulation . 100 

Weak heart 

definition . . 199 





INDEX. 


26l 


Weak heart — Continued. 




Wounds of the heart 




diagnosis 


199 


diagnosis 


. 118 


etiology 


199 


physical signs 


118 


pathology 


199 


prognosis 


. 118 


prognosis 


200 


symptoms , 


118 


symptoms 


199 


treatment 


. 119 


treatment 


200 


Yawning, a symptom of heart 


Wet pack, in 




disease 


32 


exophthalmic goitre 


209 


Zinc phosphide, in 




Wier Mitchell treatment, in 




arterio-sclerosis 


. 246 


angina pectoris 


192 


fatty degeneration 


108 


fatty accumulation 


100 


Zincum cyanide, in weak heart 201 



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